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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 33� <br /> WELL AND BORING SEALING RECORD Sealing No. 16 <br /> +Ii[ 5 <br /> County Name Minnesota Unique No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-e Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 35 SM'NE SE% A-g • g _ <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 910 Old Long Lake loo: Depth Before Sealing 11# ft. Original Depthill ft. <br /> Show exact location of well or boring Sketch map of well or boring AQUIFERS) STATIC WATER LEVEL <br /> in section grid with`X'. location, showing property Aquifer <br /> %Sin le A <br /> lines,roads,and buildings. g q 0 Multiaquifer <br /> N WELUBQ(i1NG )(Measured 0 Estimated <br /> ---1-----1----;------.--- tit <br /> Water Supply Well 0 Monit.Well <br /> Ij j totAl 0 Env.Bore Hole 0 Other ft. X below 0 above land surface <br /> 410 <br /> yy---r-----1----1-----n---` - E CASING TYPE(S) <br /> '4--"-1'_---1 1"- Steel ❑Plastic ❑Tile 0 Other <br /> I I I I r mde <br /> --------6-4-4:7-1-7,--- Diameter Depth Set in oversize hole? <br /> lll"� S /�, P C. Annualar space iniflalry grouted? <br /> st,-f mte—#f. 0 •.- tri..lir sA in.from_CI__ to 1 ft. 0 Yes 56,No 0 Yes 0 No A Unknown <br /> PROPERTY OWNERS NAME . , in.from to ft. 0 Yes 0 No 0 Yes 0 No ❑Unknown <br /> Bruce Dayton <br /> Property owner's mailing address if difte than well location address indicated above. in.from to ft. 0 Yes ❑No 0 Yes 0 No 0 Unknown <br /> 900 Old Long Lake Road SCREEWOPEN HOLE <br /> Screen from WI to { i 1 ft. Open Hole from to ft. <br /> Wayzata; .MN 55391 <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME /'IQI Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 FIll 0 No Obstruction <br /> Weil owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) LA10041e4 tot C lk <br /> Obstructions removed?)(Yes No Describe Pr.4t1tA tk4 411: CEraim caa..1 C)st+JC i <br /> PUMP �— <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS FROM TO 0 Removed X Not Present 0 Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby was or boring. USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND'BORE HOLE: <br /> la No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> 0 Other <br /> GROUTING MATERIAL(S) //�� r <br /> Grouting Material sif i:+ ce1�lff1 from. LJ to I/II ft. yards I YE. 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 OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? 0 Yes IQ 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 /> RECEIVED Stevens Drilling & Env. Services, Inc. 16654 <br /> Contractor Business(flame License or Registration No. <br /> SEP 2 91998 '� ___.-_____ 7l4l98 • <br /> CITY OF ORONO Authorized Representative Signature D81e <br /> i4 c�sd- e-14-CIS <br /> LOCAL COPY H 136325 Name of Pew Seakng Wel or Boring <br /> HE-01434-03 Pm714 <br />