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1' MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 5 7�9 8 ;: WELL OR BORING LOCATION Sealing No. H � County Name WELL AND BORING SEALiNG RECORD Minnesota Unique Well No. � Minnesota Statutes,Chapter 1031 or W-series No. � Henaspia (Leave blank if no�knownJ Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orono 118N 23ii 29 '� '� SE'° August 16, 20Q7 GPS Latitude degrees minutes seconds Depth Before Sealing_ �"O� __ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ��Single Aquifer ❑Multiaquifer 3560 6th Av� N� �11g LQs� WELUBORING �I Measured �Estimated Date Measured_8 I6 07 �Water-Supply Well �]Monit.Well Show exact location of well or boring Sketch map of well or boring . in section grid with"X" location,showing property U Env.Bore Hole ❑Other_ _ �S ft. �below ❑above land surface �# N lines,roads,and buildings. CASING TYPE(S) ' --'-- --'----`-- --'— - �f Steel ❑Plastic ❑Tile ❑Other _ � --''-' "�-'- "'`-- --'`'- WELLHEAD COMPLETION �� � W ; � � ; ET - - �� Outside: �]Well House ,_;At Grade Inside: [�Basement Offset � —�--- ---�—--�-- ---.-- ; ; ; ; ; Miie . Pitless AdaptedUnit ❑Buried ❑Well Pit �M �� --.--- --r----�-- ---:- 1 - ❑Buried S �Well Pit ❑Other i �—�nniie� ❑Other , � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) T�X and Donna �StY� Diameter Depth Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different than weli location address indicated above � in.from O to � ft. Yes � ❑No ❑Yes ❑No �Unknown 3560 6th Ave I� Loag Lake. rIII 55356 � in.from 5 to 101 ft. �Yes ❑No ❑Yes ❑No �]Unknown in.from to ft. � �Yes '.�,��No ��.��Yes �, �No r;Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Tea aad Doana Ostvi ■(� S Well owner's mailinq address it different than prooerty owrer's address indicated above SCreen from jM� _tp 10+_ .ft. Open Hole from _ to ft. OBSTRUCTIONS ❑Rods/Drop Pipe U Check Valve(s) ❑Debris ', '.Fiil �No Obstruction Type of Obstructions(Describe)_ _ _ _ GEOLOGtCAL MATERIAL COLOR HARDNESS OR FHOM TO Obstructions removed? ❑Yes �No Describe FORMATION PUMP ` ..; If not known,indicate estimated formation log trom nearby well or boring. �� { , , . TYPe �1 I :_. �C_�.__ ` ��Removed ❑Not Present ❑Other _ . METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �;No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe �J Casing Perforation/Removal in.from to _ft ❑Perforated ❑Removed in.from _to tt. ❑Perforated ❑Removed Type of Perforator_ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) 1 1 a Grouting Materiala�at C�t_ from � to 1fl5_ ft. yards2Z bags from_ ro ft. yards bags _ ___ _ from to _ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES 1N SEALING Other unsealed and unused well or boring on properry? �j Yes �j No How many? UCENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. ' Stevens Dri113ng � Environ�ental Svc Inc._____Z_�,�,� ___ ___ `- Contractor Business Name License or Registration No. ' 86b54 �17107_ . -- - - - _---- — - Certified Representative Signature Certified Rep.No. Date � 'S H 2 5 7 a 9 8 Patrick 3ohnson ; ' LOCAL COPY — — — __ __ __ _ —_ _— _ _.__ Name of Person Sealing Well or Boring j� HE-01434-09 IC#140-0423 s/osa j j� . . .. . . . .