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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I I / "� <br /> 162 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnleso aoUnique Well No. L� <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank K mt i-) <br /> Township Name Township No. I Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23W 33 SE,,, July 28, 2006 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing 55 ft. Original Depth ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location [D Single Aquifer ❑Multiaquifer <br /> 160 Old Crystal Bay Rd N, Long Lake WELUBORING Measured ❑Estimated <br /> Water Supply Well E]Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring 14 <br /> in section grid with"X" location,showing property E] Env.Bore Hole E]Other ft. �]' below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> 0 Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - -- -i-- --i-- E WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside:ZI.-Basement Offset <br /> 14mnb ❑Pitless Adapter/Unit ❑Well Pit <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> frw. 7 ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Leann Coe Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 4145 <br /> 1 n.from t0 ft. Yes [-]No Q Yes ❑No E]Unknown <br /> 60 Old Crystal Bay Rd N <br /> Long Lake, MN 55356 in.from 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 /> Leann Coe 145 155 <br /> Well owner's mailing address if different than property owner's address indicated above Screen from t0 ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill -,a;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 from nearby well or boring PUMP <br /> Type St1bID <br /> 13,,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 /> 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 lbs.) <br /> Grouting Material Cteat coir-i t from 0 to 155 ft yards I? bags <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 0 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 & Environmental Svc 2255 <br /> Contractor Business Name License or Registration No. <br /> Authorized Representative Signature D e <br /> LOCAL COPY <br /> �H241627 .Tason Ramthun <br /> Name or Person Sealing Well or Boring <br />