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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 222472 <br /> County Name WELL AND BORING SEALING RECORD Sealing No. <br /> Minnesota Unique Well 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(sm-a.-Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118H 23W 31 HE' 9-10-04 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 104 ft. Original Depth ft. <br /> LOCATION: <br /> Longitude degrees minutes seconds AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �II�.�{�-��Single Aquifer ❑Multiaquifer <br /> 46033 Watertown Rd, Maple Plain WELLIBORING j Measured ❑Estimated <br /> igr. 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 0 Env.Bore Hole ❑Other 104 ft. f Velow 0 above land surface <br /> lines,roads,and buildings. <br /> N rASING TYPE(S) 7� <br /> -t ler ;yfxti ,C <br /> fV Steel ❑Plastic 0 Tile ❑Other <br /> W E Itt113::.�++���� WELLHEAD COMPLETION <br /> Outside: 0 Well rouse Inside: ❑Basement Offset <br /> I } I I ..,k, 4ew-�� f�/Pitles Adapter/Unit 0 Well Pit <br /> Sk4 ❑Well Pit El Buried <br /> S � <br /> �--- --anis ' Wel( ._ t1i-i 0 Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> John F & Joan M Serena Diameter Depth J._15_ Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 4 0 to ft. 0 Yes 1 No ❑Yes ❑No Unknown <br /> in.fromT <br /> 4605 Watertown Rd <br /> Maple Plain, y 55359 in.from to ft. 0 Yes ❑No ❑Yes ❑No 0 Unknown <br /> in.from to ft. 0 Yes 0 No ❑Yes ❑ No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> John F & Joan,M Serena <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 135 to 140 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> pods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill It No Obstruction <br /> Type``of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? L' Yes 0 No Describe <br /> FORMATION 777��� <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type submersible <br /> Removed ❑ Not Present 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated 0 Removed <br /> in.from to ft. 0 Perforated ❑ Removed <br /> Type of perforator -- <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) 1 7 <br /> 1 <br /> Grouting Material Neat went from 0 to 140 ft. yards _lbags <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 kNo 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 is <br /> true to the best of-my knowledge. <br /> Stevens Drilling & Environmental Svc 86654 <br /> Contractor Business Name License or Registr tion No. <br /> . -"-"'"---....____ q/ , 6L1 <br /> Authorized Representative Signature Date <br /> Tim Stevens <br /> LOCAL COPY f�//�2 2 4 7 2 Name of Person Sealing Well or Boring <br />