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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 241618 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota SealingNo. <br /> Well No. <br /> IHennepin Minnesota Statutes,Chapter 1031 <br /> 3.Ln e.i@pin or W-series No.(Leave Wank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm—Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23W 33 NE June 15, 2006 'iECEIVEc <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 1 5`, _ - ft. Original Depth JUL 2 4 f� <br /> LOCATION: /006 <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER AVEL C <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer L /7-y n i. <br /> 2765 W Wayzata Blvd, Long Lake wELLBORING [ Measured ❑Estimat 0iluNO <br /> cz Water Supply Well ❑Monit.Well lA <br /> Show exact location of well or boring Sketch map of well or boring - 124 <br /> in section grid with"X" ', location,showing property ❑Env.Bore Hole ❑Other ft. ®below ❑above land surface <br /> Na lines,roads,and buildings. CASING TYPE(S) <br /> FvT Steel ❑Plastic ❑Tile ❑Other <br /> W---r---,----r-'--,- E `°'j , 1- L' ` WELLHEAD COMPLETION <br /> --- 1 i Outside: ❑Well House Inside: ❑Basement Offset <br /> I f I t,ff,b ❑Pitless Adapter/Unit ,Well Pit <br /> i -74 <br /> i..r ❑Well Pit ❑Buried <br /> ,,,J <br /> ) € ❑Buried <br /> I <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> VCI Capital. Diameter Depth Set in oversize hole'? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above148 <br /> 3 in.from 0 to ft. ❑Yes ;61,.No ❑Yes ❑No kl]Unknown <br /> PO Boggy 375 'C <br /> Long Lake, MN 55356 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes E No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> All <br /> VCI Capital. <br /> Well owners mailing address if different than property owner's address indicated above Screen from 1 48 to 1 S 2 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill Olk No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring • <br /> Type t }er <br /> )(Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material neat cement from 0 to 152 ft. yards 8 bags <br /> from to ft. - yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property'? ❑ Yes K 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 /> Stevens Drilling & PNvironm{_rttal Svc Inc 2255 <br /> Contractor Business Name License or Registration No. <br /> (1,',.-r-j i:1' I ; '''' <br /> r ,, / 1 <br /> p Authorized Representative Signature Date <br /> LOCAL COPY <br /> H 2 1618 Jason Ramthun <br /> Name of Person Sealing Well or Boring <br />