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Name MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 255784 7 A <br /> County Na <br /> WELL BORING LOCATION WELL AND BORING SEALING RECORD Minnesota <br /> No.oUnique Well No. �.? 1 i} <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin (Leave tolank II not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23V 32 '/ '/SH/, January 26, 2007 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 136 ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 3940 Nat@moan Rd, E)rt 0 WELLBORING !k Measured ❑Estimated Date Measured 1/26/07 <br /> / <br /> Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X:' location,showing property ❑Env.Bore Hole ❑Other 97ft. fl below ❑above land surface <br /> N lines,roa�,apf buildings. CASINGTYPE(S) <br /> C l <br /> 1 I Steel ❑Plastic ❑Tile ❑Other <br /> --i----- ------------- <br /> WELLHEAD COMPLETION <br /> , T <br /> W E1 <br /> ❑ <br /> ____'__ ____'__ Outside: ❑Well House ❑At Grade Inside: Basement Offset <br /> 'k Mile ❑Pitless Adapter/Unit ❑Buried Well Pit <br /> ---- - -- ------- <br /> ❑Buried <br /> S ❑Well Pit <br /> ❑Other <br /> )- 1 Mile ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Br IAM Mcconnell Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 4 in.from is 0 t0 132 ft. ❑Yes g]No ❑Yes ❑No X Unknown <br /> 6249 Cavendish Place <br /> Eden Prairie, MN 55346 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> Brian McConnell <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 132 to 136 ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill :J No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? L]Yes E]No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Type <br /> ❑Removed ]Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIALS) (One bag of cement=94 Ibs.,one <br /> ♦bag <br /> �of bentonite=50 lbs.) <br /> Grouting Material Neat `t.�! from 0 to 136 ft. yards_ bags <br /> from _ to_ ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I No How many? <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 <br /> is true to the best of my knowledge. <br /> Stevens Drilling 6 Environeental Svc 2255 <br /> Contractor Business Name License or Registration No. <br /> 1/26/07 <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY <br /> " 25578 ` �""' <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 ICN 140-0423 6/06R <br />