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,.. WELL OR BORING�OCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 O V'T <br /> Counry Name <br /> WELL AND BORING SEALING RECORD M nn'egoNa Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave bl2nk i�no�known) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 N$ N& NE. $-&-03 � <br /> GPS Latitude degrees minutes seconds 57 R�CEIVE ` <br /> LOCATION: Depth Before Sealing ft. Original Depth <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer � Q Ur ) ^ ��0� <br /> 1625 Bohns Point �� Orono W VBORING tv�easured ❑ estimated � � % <br /> [�Water Supply Well ❑Monit.Well <br /> Show exact location of well or boring e Sketch map of well or boring C CITY /'�� <br /> in section grid with"X" r�t..,_.� i A location,showing property ❑ Env.Bore Hole ❑Other _ 2J ft. below ❑ab��a T i d«�O <br /> � � �� lin r ads,and buildings. <br /> N �/,�� � Lz-1_� CASING TYPE(S) <br /> 1.�'-X���� [y[Steel ❑Plastic ❑Tile ❑Other <br /> '���i��.�-="� /\ <br /> W -�- -�-� -;-- --;— E WELLHEAD COMPLETION '' <br /> , � � � � �`��`-"'`� 1 / Outside: ❑Well House Inside: [�Basement Offset : <br /> --�- --- - — --�-- <br /> ^'�� ❑ Pitess Adapter/Unit ❑Well Pit <br /> -�-- -i— -i-- --�-- � �� �; <br /> �•;T p� j�l�'i � ❑Well Pit ❑Buried <br /> S <br /> �1 mib <br /> ❑Buried <br /> PROP„�(��YlarEF3$O�S OMPANY NAME CASING(S) <br /> Yl Il Diameter Depth Set in oversize hole? Annular space initiall;�grouted? <br /> Property owner's mailing address if different than well location address indicated above .�/ <br /> 3 in.from � to 53 ft. ❑Yes �yNo �Yes ❑No �Unknown <br /> 125 Lake St W '` <br /> Wayzata, � 55l�1 in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Pillar Homes <br /> Well owners mailing address if diNerent ihan property owner's address indicated above Screen from �3 t0 57 ft. Open Hole fi Of11 t0 ft. <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? ❑YeS ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring PUMP <br /> Type jet <br /> Removed ❑ Not Present ❑Other <br /> i <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 pertorator <br /> ❑ Other <br /> GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material Ne�t Cemen t from�to—��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,DIPFICULTIES 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 Drtlling 6 Ennironaental Svc 8b654 <br /> Contractor Business Naq�e License or Registration No. <br /> ,:' S <br /> ti <br /> ; , '�, ._ -`"--.--...._ � �k..() 3 <br /> Authorized Represenfative Signature Date <br /> H �O���� Rich�rd Stevens �- �,� - �)� <br /> LOCALCOPY <br /> Name of Person Sealing Well or Boring <br />