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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 0 5 5 7 8 WELL AND BORING SEALING RECORD Mennfego a�Unique Well No. - County Name - ge�ep� Minnesota Statutes, Chapter 1031 oeaW-serieskNo. Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orono 118N 23W 26 SW 3i/ SW Sept. i4, 2Q12 GPS Latitude degrees minutes seconds Depth Before Sealing 98 ft. Original Depth ft. � LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL �- Numerical Street Address or Fire Number and City of Well or Boring Location ',�Single Aquifer ❑Multiaquifer e L 248� Long Lak� BIVt�� Loag Lake 55356 WELL/BORING �Measured r�Estimated Date Measured 7 ��F 12 _ ',�Water-Supply Well ❑Monit Well Show ezact location of well or boring Sketch map of well or boring ,—, in section grid with"X." location,showing property �r]Env.Bore Hole ❑Other _ _.___Q�_ft. �below i ;above land surface N lines,roads,and buildings. CASING TYPE(S) : �-� --'-----'--- ---`—--'-- S �Steel ❑Plastic ❑Tile ❑Other --'--- --�------`-- ---�-- WELLHEAD COMPLETION � W � � � � E � � � � T ��';1� Outside: iJ Weli House ❑At Grade Inside: ❑Basement Offset ;��. � --�-----�-----�-- ---%— � vl � nn;ie '�Buried ❑Well Pit � � � � � '> tless A p dUnrt U ; ; , ; � [�i da te g -- ----�-- ---�-- -�-�- � ' ❑Buried S ' ❑Well Pit ❑Other F-1 Mile� --^""'� ❑Othef .t' �� PROPEFTY OWNER'S NAME;COMPANY NAME CASING(S) Reith �asdenbranden Diameter Depth Set in oversize hole? Annular space initially grouted? Pro ert owner's mailin address if different than well location address indicated above 1�4�V j.,0i1g9 T.8�C B�Vti �in.from� to�ft. �Yes ❑No �Yes ❑No ❑Unknown I.o�n.g Lake, �I 55356 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �eith Vandenbranden AL � Well owner's mailing address if different than property owner's address indicated above Screen irorn 7Y _to 9� ft. Open Hole from to ft. ' t OBSTRUCTIONS i,�RodsiDrop Pipe i�Check Valve(s) �]Debris ��Fill 'i_I,No Obstruction Type of Obstructions(Describe)_._dZOp �j.� � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? [�Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. Type S�l�?ffi �$Removed ❑Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �;�No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other � GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material Y1EA� CE'�EII� from d to ga ft. yards 8 bags ___ from_ to fl. yards bags r from to ft. yards bags OTHER WELLS ANO BORINGS �i REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes �No How many? - � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. Stevens Drillin_�Bnv. _ -. It�c. __ 2255 Licensee Business Name License or Registration No. '�____ \ 556 9/17/22 iied Representative Signature Certilied Rep.No. Date 305578 Ti�t Stevens LOCALCOPY H _ __. —_ Name ol Person Sealing Well or Boring HE-01434-12 IC#140-0423 sio9a