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Minnesota Well and Boring 28907 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota unique No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> 1 (Leave blank if not known) <br /> Township Name Township No I Range No. Section No. Fraction ism. ,Ig.) Date Sealed Approximate Date Well <br /> Orono 118N 23V <br /> 3 S tlSE lNW 14 4/28/93 or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 142 <br /> 425 N. Old Crystal Bay Road Depth Before Sealing ft. Original Depth ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level ❑Accurate <br /> in section grid with"X. location.showing property lines. <br /> N roads.and buildings. Approximate <br /> Single Aquifer ❑Multiaquifer ft. X below above land surface <br /> t t i i <br /> -�- - - - -t- CASING TYPE " <br /> W t Ix E <br /> T <br /> Steel El Plastic El Tile ❑Other <br /> a mile <br /> S Screen from to ft. Open Hole from to ft, <br /> t mile OBSTRUCTION/DEBRIS/FILL qt <br /> PROPERTY OWNER'S NAME PJ Obstruction ❑Debris ❑Fill L, <br /> tl ; <br /> G. L. Vickermn � rods 4 <br /> Type of debris/obstruction <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? IX Yes ❑No <br /> 425 N. Old Crystal Bay Road' PUMP <br /> Orono, int 55356 $ �g3 <br /> X Removed ❑Not Present ❑ Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> IF not known,indicate estimated Formation log from nearby well or boring. <br /> 2 in.from to ft. ❑Yes IN No ❑Yes ❑No 99 Unknown <br /> in.from to Ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ®No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑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 <br /> Grouting material neat cewnt from 142 to 0 ft. yards 3 bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft yards bags <br /> from to ft yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? Yes ❑No in use <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 Well Drilljng DrillingCo. 27194 <br /> Contractor Business Name License or Registration No. <br /> 4129193 <br /> Authorized Pepresentattve Signature Date <br /> LOCAL COPY �' n n n O Randy Johnson 4/29/93 <br /> Ga`� Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />