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Minnesota Well and Boring H 59528 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> County NameWELL AND BORING SEALING RECORD Minnesota Unique No. <br /> I. Minnesota Statutes.Chapter 1031 or W-series No. <br /> nennep (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(Sm. •Igg..)r Date Sealed Approximate Date Well <br /> Orono 118 23 35 SW NE4 s6 1/12/95 orBorngConstructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location1_ 3 <br /> 910 Old Long Lake Road, Depth Before Sealing ft. Original Depth 135ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level 0 Accurate <br /> in section grid with"X-. location.showing property lines, <br /> roads.and buildings. 0 Approximate <br /> N <br /> I <br /> 72 <br /> t Single Aquifer 0 Multiaquifer ft. . below above land surface <br /> �-�---L---t-- CASING TYPE <br /> W -- i E <br /> I *T <br /> -t r---t-- <br /> 1 Steel 0 Plastic 0 Tile 0 Other <br /> 1 :f mire Ill.,, - s - .... <br /> I <br /> . <br /> S <br /> Screen from to 135 ft. Open Hol r-. ft, <br /> 1.4.-1 mire--Koi OBSTRUCTION/DEBRIS/FILL {r E U <br /> PROPERTY OWNERS NAME 0 Obstruction 0 Debris 0 Fill <br /> Bruce Dayton ate_ <br /> Mailing Address if different than property address indicated above. Type of debris/obstruction <br /> Obstruction/Debris/Fill removed? 0 Yes ❑No '411111 1 71995 <br /> 900 Did Long Lake Road PUMP j"''�'� <br /> Wayzata, MN 55391 r>r„ A ei .... ._ <br /> ❑Removed Not Present 0 Other <br /> • CASING 111111 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO • <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> 4 <br /> in.from to 130 ft PYes 0 No ❑Yes 0 No l( Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: , <br /> 1$No Annular Space Exists <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 /> • <br /> Type of perforator • <br /> ❑Other <br /> 'GROUTING MATERIAL <br /> . Grouting material Neat Cement. 0 to 135 ft. yards 6 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 y. <br /> Other unsealed well or boring on property? 0 Yes 0 No unknown <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 /> St ant Dr ling & Ear. $6684 <br /> Contra vans Nam License or Registration No. <br /> !III <br /> t , <br /> 1/13/95 <br /> Autho -• 1 resentative Signature Date <br /> LOCAL COPY H 59528Paul Swearengin <br /> Name of Person Sealing Well or Bonng <br /> HE•01434-01 <br />