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MINNESOTA DEPARTMENT OF HEALTH • Minnesota Well and Boring 17 Q 1 A O
WELL OR BORING LOCATION - • Sealing No. H Q 3 Q
County Name — WELL AND BORING SEALING RECORD Minnesota Unique Well No. C-
�� � Minnesota Statutes,Chapter 1031 or W-series No.
(Loon Monk x not known)
Township Name Township No. Range No. Section No. Fraction(sm.-s lg.) Date Sealed Dale Well or Boring Constructed
Orono 118 23 31 AJ 6-12-01
NumericalStreetAddress or Fire Number and City of Well or Boring Location
4100lSWatertown Rd, Orono Depth Before Sealing _118_ _ ft. Original Depth __. ft
Show exact location of well or boring Sketch map of well or boring ADUIFER(S) STATIC WATER LEVEL
in section grid with"X'. location, showing property s 'Single Aquifer ❑ Mulbaquifer
lines,roads,and buildings. Y
N WELL/BORING {A Measured ❑ Estimated
'Water Supply Well ❑Monit.Well e►
0 Env.Bore Hole ❑Other 70 ft. St below ❑above land surface
wc---'----Ty �---E CASING TYPE(S)
II
-F--- ----i + Steel ❑Plastic ❑Tile ❑ Other
I I I I Ytmik
t- -¢- -1 1_-- I CASING(S)
Diameter Depth Set in oversize hole? Annular space initially grouted?
lll� S "
fit--1 mire-fir 4 in.from O to 114ft. ❑Yes `�No ❑ Yes 0 No Unknown
PROPERTY OWNER'S NAME I in.from to _. ft. 0 Yes '0�No ❑Yes ❑No 0 Unknown
The Craig Company
Property owner's mailing address if different than well location address indicated above. • in.from to ft. 0 Yes 0 No ❑ Yes ❑No 0 Unknown
1300wnWillowbrook Dr SCREEN/OPEN HOLE
Wayzata, MN 55391 Screen from 114 to 118 ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME 0 Rods/Drop Pipe 0 Check Valve(s) ❑Debris 0 Fill 'No Obstruction
The Craig Company
Well owners mailing address if different than property owner's address indicated above. Type of Obstructions(Describe)
Sane Obstructions removed? 0 Yes ❑No Describe
PUMP
Type Sub.
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed 0 Not Present 0 Other
FORMATION
t not known,indicate estimated formation log from nearby well or bo ng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
`JNo Annular Space Exists
Wo
space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Neat Cement 0 118 9
Grouting Material from - to ft. yards bags
from to ft. yards bags
from to ft. yards bags
from to_ ft. _ yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS + n yr
k T u u M
Other unsealed and unused well or boring on property? 0 Yes LI No How many? kJ,� N+N+a 1..�
-LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
true toto�the best of my knowledge.ilip S
•
CosnTractor usmess filling & Env. Services License or Re8g6(FaTi 4P+o
•
\'; —�` (o—J —01
•Authorized Representative Signature Date
Richard Stevens
LOCAL COPY H
w 78
1 38� Name of Person Sealing Well or Boring