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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 28920 <br /> County Name WELL AND BORING SEALING RECORD Minnesota unique No. <br /> Hennepin Minnesota Statutes, Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township Name Township No. Range No Section No. Fraction ism. •Ig.) Date Sealed Approximate Date Well <br /> Orono I 18 23W 32 SEt,4SW),,SEt1a 8/6/93 or Boring Constructed 1960 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 3445 Watertown Road Long Lake Depth Before Sealing 165 ft Original Depth ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level X Accurate <br /> in section grid with..X... location,showing property lines. <br /> N roads.and buildings. ElApproximate <br /> IX Single Aquifer ElMult,aquifer 10 it X below above land surface <br /> CASING TYPE <br /> W E <br /> IX Steel El Plastic ❑Tile El Other <br /> m <br /> �ile DEC- <br /> ' VV"y+JJ�. <br /> S Screen fromto 165 ft. Open Hole from to ft. <br /> I mile 1 OBSTRUCTION/DEBRIS/FILL <br /> L7 Obstruction EJ Debris El Fill <br /> PROPERTY OWNER'S NAME '•: i <br /> Ward Ferrell drop 1" i <br /> --- -----, - Type of debris/obstruction 126 ? p pire <br /> Mailing Address if different than property address indicated abover, 1�t It <br /> f —J{t� Obstruction/Debris/Fill removed? [XYes El No <br /> 3415 Watertown Road PBMP <br /> Long Lake, MN 55356 <br /> Removed ❑Not Present ❑ Other f <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OFFORMATION FROM TO <br /> ' <br /> If not known,indicate estimated formation log from nearby well or boring. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> 3 in.from 0 to 160 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> infrom to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material neat cement from16Sto 0 ft. yards 5 bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes ❑No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Stevens Well Drilling Co. Inc. 27194 <br /> Contractor Business Name �. License or Registration No. <br /> ,- 9/3/93 <br /> Authorized Representative Signature Date <br /> LOCALi H 2 8 9 2 0 Dan Maas <br /> C Name o/Person Sealing Well or Boring <br /> HE-01434-01 <br /> * - <br />