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Minnesota Well and Boring 59529 <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 /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well <br /> Orono <br /> 118 23 _ 35 SVNE"4SEr4 1/12/95 or Boring Constructed <br /> Numerical <br /> Street Address or Fire Number and City of Well or Boring LocationI j q <br /> 990 Old Long Lake Road Depth Before Sealing • 131 ft. Original Depth 131 ft <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 /> I Y <br /> I <br /> Single Aquifer 0 Multiaquifer 76 h• I below above land surface <br /> ` -i---I-- CASING TYPE <br /> W i E <br /> I X Steel 0 Plastic 0 Tile 0 Other <br /> 1 I <br /> t 126 131 <br /> S Screen from to ft. Open Hole from to ft. <br /> N---r mile OBSTRUCTION/DEBRIS/FILL <br /> PROPERTY OWNER'S NAME • <br /> ❑Obstruction ❑Debris 0 Fill <br /> Bruce Dayton none <br /> Mailing Address if different than property address indicated above. Type of debris/obstruction <br /> Obstruction/Debris/Fill removed? 0 Yes 0 No <br /> 900 Old Long Lake Read PUMP <br /> Wayzata, MN 55391 <br /> 0 Removed 0 Not Present 0 Other <br /> CASING <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 /> 3 in.from 0 to 126 ft. 'it Yes ❑No ❑Yes ❑No ''A Unknown <br /> in.from to ft. ❑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 /> ❑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 /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL g <br /> Grouting materfatNea Cement from to: 1 Z 6 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 0 No d n k ROWS <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 Dril . ! "`t Env. 66654 <br /> Contractor Business Na•- License or Registration No. <br /> - AO - 1/13/95 <br /> Authorized'_• =sentative SignatureDate <br /> LOCAL COPY H 595529Paul Swearangin <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />