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WEL� OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
Cou�ty Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No.
Hennepin Mmnesofa Sta�utes.Chapter 1031 OeW banke,iSoNOoWn1
Townsh�p Name Township No Range No Section No Frection�sm. �Ig� Date Sealed Approwmale Date Well
Oruno 11� G3 LV ��Q�J���� ��a 10/4i95 o�BonngConsiructed
Numencal Slreet Atldress or Fire Number and Cdy ol Well or Bonng Location
`L811 Casco Point Boad Depth Belore Seahng $7 �t Onginal Depih ft
Show exact IocaUon of weli or bonng Sketch map of well or bonng S�atic Water Level ❑Accurate
in section gnd wdh��X". location.showing property lines.
roads.and bwldings ❑Approximate
N
�Smgle AquAer ❑Multiaqwfer 56 tt. �6elow above land sudace
i �
_i_ _�_ _i_ CASING TVPE �
w -- E
-- - - -f- --
� i � �Steel ❑Plastic ❑TJe ❑Olher
miie
i i �] o
S I � Screen from �`� b v� It Open Hole irom to f�.
��""�e �1 OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME ❑Obst�uction ❑Debris ❑Fill NOV L �2 1��
i
Gwen Ross
Type of debns/obstruction
Mailing Address il diHerent Ihan prope�y address indicated above.
Obsiruchon/Debns/Fill removed� ❑Ves ❑No
Z811 .�.5$CO Point Aoad pUMP
Oroi�o, 2sAI 55323
�Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO .
FORMATION
Diameter Depth Set m oversize hole� Annular space initialty grouted?
If not known,mtlicale estimaled lormahon log irom nearby well or bonnq. 4
2 in irom � lo �J fl ❑Yes Ljf+No ❑Yes tallo ❑Unknown
in.from to t�. ❑Yes ❑No ❑Ves ❑No ❑Unknown
in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE:
�.No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Pertoration/Removal
in.(rom ro fl. ❑Perfora�ed ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type ot peAorator
❑Other
GROUTING MATERIAL
G�outing ma�erial �eat C.'4='��At �rom a to $7 ft. yards z bags
irom to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to f�. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on propeAy7 ❑Yes .No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or bonng was sealed m accordance with Minnesota Rules,Chapter 4725.The mformation contained m ihis repon is
� true to ihe best of my knowledge.
Stever�s Drilli3ig & En�r. Se$vicea, tnc. 86654
ConVactor Business Name L�cense or Registiabon No.
_.____ 1{��4I95
Author¢ed Representa6ve Signafure Date
Rich�rd Stevens
���� � ��.9 [ Name ol Person Sealrng Well or Bonng
HE-01434-01