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.. >; • <br /> MINNESOTA DEPARTMENT OF HEALTH • Minnesota Well and Boring 17 Q 1 A O <br /> WELL OR BORING LOCATION - • Sealing No. H Q 3 Q <br /> County Name — WELL AND BORING SEALING RECORD Minnesota Unique Well No. C- <br /> �� � Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Loon Monk x not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-s lg.) Date Sealed Dale Well or Boring Constructed <br /> Orono 118 23 31 AJ 6-12-01 <br /> NumericalStreetAddress or Fire Number and City of Well or Boring Location <br /> 4100lSWatertown Rd, Orono Depth Before Sealing _118_ _ ft. Original Depth __. ft <br /> Show exact location of well or boring Sketch map of well or boring ADUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'. location, showing property s 'Single Aquifer ❑ Mulbaquifer <br /> lines,roads,and buildings. Y <br /> N WELL/BORING {A Measured ❑ Estimated <br /> 'Water Supply Well ❑Monit.Well e► <br /> 0 Env.Bore Hole ❑Other 70 ft. St below ❑above land surface <br /> wc---'----Ty �---E CASING TYPE(S) <br /> II <br /> -F--- ----i + Steel ❑Plastic ❑Tile ❑ Other <br /> I I I I Ytmik <br /> t- -¢- -1 1_-- I CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> lll� S " <br /> fit--1 mire-fir 4 in.from O to 114ft. ❑Yes `�No ❑ Yes 0 No Unknown <br /> PROPERTY OWNER'S NAME I in.from to _. ft. 0 Yes '0�No ❑Yes ❑No 0 Unknown <br /> The Craig Company <br /> Property owner's mailing address if different than well location address indicated above. • in.from to ft. 0 Yes 0 No ❑ Yes ❑No 0 Unknown <br /> 1300wnWillowbrook Dr SCREEN/OPEN HOLE <br /> Wayzata, MN 55391 Screen from 114 to 118 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME 0 Rods/Drop Pipe 0 Check Valve(s) ❑Debris 0 Fill 'No Obstruction <br /> The Craig Company <br /> Well owners mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Sane Obstructions removed? 0 Yes ❑No Describe <br /> PUMP <br /> Type Sub. <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed 0 Not Present 0 Other <br /> FORMATION <br /> t not known,indicate estimated formation log from nearby well or bo ng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> `JNo Annular Space Exists <br /> Wo <br /> space grouted with tremie pipe <br /> ❑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 MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Neat Cement 0 118 9 <br /> Grouting Material from - to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ ft. _ yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS + n yr <br /> k T u u M <br /> Other unsealed and unused well or boring on property? 0 Yes LI No How many? kJ,� N+N+a 1..� <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 toto�the best of my knowledge.ilip S <br /> • <br /> CosnTractor usmess filling & Env. Services License or Re8g6(FaTi 4P+o <br /> • <br /> \'; —�` (o—J —01 <br /> •Authorized Representative Signature Date <br /> Richard Stevens <br /> LOCAL COPY H <br /> w 78 <br /> 1 38� Name of Person Sealing Well or Boring <br />