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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 115613 <br /> WELL AND BORING SEALING RECORD Sealing No. H <br /> County Name Minnesota Unique No. - <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.+Ig.) Date Sealed Date Well or Boring Constructed <br /> ©I Bono 118 23 35 N uN SEN 12/30/97 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 840 Old Long Lake Road Depth Before Sealing 139 ft. Original Depth ft. <br /> Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with*V. to tion showing property Single Aquifer ❑ Multiaquifer <br /> line roads,and buildings. <br /> NWELL/BORING XMeasured 0 Estimated <br /> I I f ..-(S, <br /> , x Water Supply Well 0 Monit.Well <br /> ( ❑ Env.Bore Hole ❑Other 52 ft. IN below 0 above land surface <br /> W I — , , E CASING TYPE(S) <br /> - T $J Steel ❑ Plastic ❑Tile ❑Other <br /> I I I 1 Si mile <br /> --+---1----1 -I--- 1 1O CASING <br /> S Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> 11._t mile—Ito /titot)4 4 in.from to 135 ft 0 <br /> 0 Yes X No 0 Yes g]No 0 Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> Bruce Dayton <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> 900 Old Long Lake Road SCREEWOPEN HOLE <br /> Screen from 135 to 139 ft. Open Hole from to ft. <br /> Orono, MN 55391 <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME <br /> 0 Obstruction 0 Debris ❑ Fill a No Obstruction <br /> Well owner's mailing address If different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? 0 Yes ❑ No <br /> PUMP <br /> Type3/4 Sump <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO 1 Removed ElNot Present 0 Other <br /> FORMATION <br /> h not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XI No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> 0 Casing Perforation/Removal <br /> In.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material Neat Cem. from 0 to 139 ft. yams 11 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? 0 Yes X0 No <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 ruling S. Env.2-7p7„1" ;, 866548 <br /> C ctor Business me License or Registration No. <br /> � 12/30/97 <br /> Authorized Representative Signature Date <br /> l <br /> in <br /> IMPORTANT-FILE WITH PROPERTY Name oP errson SealingeWellrBrYrTrrg en <br /> PAPERS-WELL OWNER COPY H 115 613 • <br /> HE-01434-02 <br /> 10/95R <br />