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��..-, - _ . . . ,. . ,. _ . ,. <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 O�H�Z <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin «aa�a b�a�k�„o,��ow�, <br /> Township Name Township No. Range No. Section No. Fraction(sm�ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 NE NE� NE' 8-8-03 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing �II ft. Original Depth ft. <br /> Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 1525 Bohns Point Rd, Orono E UBORING �/tvteasured ❑ estimated QUG 2 9 2003 ` <br /> �Water Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring 22 <br /> in section grid with"X" � bcation,showing property ❑ Env.Bore Hole ❑Other ft. f�l/below a ove d surface . <br /> N ' ���`,J � j�hnes,ro�ds and buildin s. CASING TYPE(S) �� <br /> � �� <br /> y Steel ❑Plastic ❑Tile ❑Other � <br /> !���r.�,�r ��i�. <br /> -�- -;-- -;-- --;— � � WELLHEAD COMPLETION <br /> W --- - -;-- --�— � t'��'j{= ..L._ .�. <br /> Outside: ❑Well House Inside: ❑Basement Offset ' <br /> - -- f- 3����f.�f! ` <br /> �� � ❑Pitess Adapter/Unit ❑Well Pit <br /> --�- -i-- -i - --�-- � <br /> S � 4 f -j �i �� �� �Well Pit ❑Buried <br /> �' CJ` <br /> �r mde <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Pil lar HODI@ S Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above L <br /> � in.from � tp �•f ft. ❑Yes -f�No ❑Yes ❑ No �Unknown <br /> 'r\ <br /> 125 Lake St W <br /> Wayzata, HId 55391 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> P11�.8I $o15eS <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 44 t0 4� ft. Open Hole from t0 n. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y0S ❑ NO DeSCflb2 <br /> FORMATION - <br /> tl not known,indicate estimated formation log irom nearby well or boring PUMP <br /> Type h_ Ftnc1 �t� <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 /> .� <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 Ibs.,one bag of bentonite=50 Ibs.) <br /> " Grouting Material�e e�.���� irom_�_to��ft. yards �_ bags <br /> from to ft. yards bags <br /> from to ft yards bags ' <br /> OTHER WELLSAND BORINGS <br /> REMARKS,SOUACE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes 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 is <br /> true to the best of my knowledge. <br /> Stevens Drilling & Enniro�ental Svc 86654 <br /> Contractor Business Name. License or Registration No. <br /> \ \ - <br /> ' �`,� -- =:�.._._ g-��-U 3 <br /> Autho�ized Representative Signature Date <br /> 2 Q 18 4 2 Richard Stevens ZS - ��' (�3 <br /> LOCAL COPY H Name ol Person Sealing Well or Boring <br /> ... j� , . . . . . - . . . _ . . . .._ . .. . ... � <br />