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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 241648 <br /> o. <br /> County Name <br /> WELL AND BORING SEALING RECORD SealMinnlesotta Unique Well No. <br /> Minnesota Statutes,Chapter 1031 <br /> Hennepin or W-series No. <br /> (Leave Wank ii rat kmw,) <br /> Township Name Township No. Range No. Section No. Fraction(sm-i-Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 113N 23W 33 S'- ,. Septwnber 29, _006 <br /> GPS Latitude degrees minutes seconds 151 <br /> LOCATION: Depth Before Sealing ft. Original Depth_ h. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ETSingle Aquifer ❑Multiaquifer <br /> 425 Old Crystal Bay Rd N, Ororo WELL/BORING Measured ❑Estimated <br /> [Q,Water Supply Well E]Monit.Well <br /> Show exact location of well or boring Sketch map of well or bo 78 <br /> in section grid with"X" /� location,showing prope ❑Env.Bore Hole E]Other ft. &J below ❑above land surface <br /> N lines,roads,and building CASING TYPE(S) <br /> [Steel E]Plastic ❑Tile ❑Other <br /> W - ------:-- -;-- --i-- E fi +- WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: ❑Basement Offset <br /> i — <br /> )✓lmib " [XPitless Adapter/Unit ❑Well Pit <br /> 4_4_4_ <br /> --i-- <br /> ❑Well Pit ❑Buried <br /> 5.. it s. I r <br /> ` <br /> . <br /> ❑Buried <br /> PROPERTY OWNER'S NAMEICOMPANY NAME CASING(S) <br /> Land Ventures, LLC Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above150 <br /> in.from t0 ft. ❑Yes No Yes E]No Unknown <br /> 7847 Creekridge Circle <br /> 1113inn_eapolis, MN 55439 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 /> Land Ventures, LLC �1 <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 150 to 154 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ba No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OFORMATION R FROM TO Obstructions removed? ElYes ElNo Describe <br /> If not known,indicate estimated formation log from nearby well or boring If <br /> Type SUbID <br /> tQ Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [k 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 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material neat Cummitt from 0 to 154ft. yards 1 7 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 EX 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 /> OCT 1 sevens vrilliag & Environmental_ Services, Inc 2255 <br /> Contractor Business Name License or Registration No. <br /> CITY 4F C,t,',L, <br /> 9/29/06 <br /> Authorized Representative Signature Date <br /> Windy Johnson <br /> LOCAL COPY H 241648 <br /> Name of Person Sealing Well or Boring <br />