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Minnesota Well and Boring � � <br /> WEL� OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> Cou�ty Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. <br /> Hennepin Mmnesofa Sta�utes.Chapter 1031 OeW banke,iSoNOoWn1 <br /> Townsh�p Name Township No Range No Section No Frection�sm. �Ig� Date Sealed Approwmale Date Well <br /> Oruno 11� G3 LV ��Q�J���� ��a 10/4i95 o�BonngConsiructed <br /> Numencal Slreet Atldress or Fire Number and Cdy ol Well or Bonng Location <br /> `L811 Casco Point Boad Depth Belore Seahng $7 �t Onginal Depih ft <br /> Show exact IocaUon of weli or bonng Sketch map of well or bonng S�atic Water Level ❑Accurate <br /> in section gnd wdh��X". location.showing property lines. <br /> roads.and bwldings ❑Approximate <br /> N <br /> �Smgle AquAer ❑Multiaqwfer 56 tt. �6elow above land sudace <br /> i � <br /> _i_ _�_ _i_ CASING TVPE � <br /> w -- E <br /> -- - - -f- -- <br /> � i � �Steel ❑Plastic ❑TJe ❑Olher <br /> miie <br /> i i �] o <br /> S I � Screen from �`� b v� It Open Hole irom to f�. <br /> ��""�e �1 OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME ❑Obst�uction ❑Debris ❑Fill NOV L �2 1�� <br /> i <br /> Gwen Ross <br /> Type of debns/obstruction <br /> Mailing Address il diHerent Ihan prope�y address indicated above. <br /> Obsiruchon/Debns/Fill removed� ❑Ves ❑No <br /> Z811 .�.5$CO Point Aoad pUMP <br /> Oroi�o, 2sAI 55323 <br /> �Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO . <br /> FORMATION <br /> Diameter Depth Set m oversize hole� Annular space initialty grouted? <br /> If not known,mtlicale estimaled lormahon log irom nearby well or bonnq. 4 <br /> 2 in irom � lo �J fl ❑Yes Ljf+No ❑Yes tallo ❑Unknown <br /> in.from to t�. ❑Yes ❑No ❑Ves ❑No ❑Unknown <br /> in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> �.No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Pertoration/Removal <br /> in.(rom ro fl. ❑Perfora�ed ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type ot peAorator <br /> ❑Other <br /> GROUTING MATERIAL <br /> G�outing ma�erial �eat C.'4='��At �rom a to $7 ft. yards z bags <br /> irom to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to f�. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on propeAy7 ❑Yes .No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonng was sealed m accordance with Minnesota Rules,Chapter 4725.The mformation contained m ihis repon is <br /> � true to ihe best of my knowledge. <br /> Stever�s Drilli3ig & En�r. Se$vicea, tnc. 86654 <br /> ConVactor Business Name L�cense or Registiabon No. <br /> _.____ 1{��4I95 <br /> Author¢ed Representa6ve Signafure Date <br /> Rich�rd Stevens <br /> ���� � ��.9 [ Name ol Person Sealrng Well or Bonng <br /> HE-01434-01 <br />