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v <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 115664 <br /> Minnesota AND BORING SEALING RECORD SealingH <br /> County Name Minnessottao Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.- Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 r4 u 14 <br /> 11/241/97 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location p <br /> 51 North Willow Drive Depth Before Sealing 8 5 ft. Original Depth ft. <br /> — <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property XJ Single Aquifer 0 Multiaquifer <br /> lines,roads,and buildings. <br /> N WELL/BORING )(J Measured ❑ Estimated <br /> 0 Water Supply Well El Monit.Well <br /> _-T_—_T____,-_-__l__- C q <br /> ❑ Env.Bore Hole ❑Other 5 4 ft. )J below ❑ above land surface <br /> W r —I I E CASING TYPE(S) <br /> I I <br /> ---I--`--I -I I NJ Steel El Plastic El Tile 0 Other <br /> I I I I a mire <br /> i_ _-I__ I i___ I CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S <br /> liJ <br /> (r t mile <br /> 4 in.from _ to 81 tt. ❑Yes )0 No El Yes I7]No $ 1 Unknown <br /> PROPERTY OWNER'S NAME I in.from to ft. ❑ Yes El No ❑Yes ❑No 0 Unknown <br /> Mrs Ivan Gunsolus <br /> Property owners mailing address if different than well location address indicated above. in.from to ft. 0 Yes ElNo ❑ Yes 1:]No 0 Unknown <br /> 51 North Willow D r. SCREEN/OPENHOLE q <br /> Orono , MN 55323 Screen from 81 to 84 ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME <br /> 0 Obstruction 0 Debris 0 Fill J No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill <br /> Obstruction/Debris/Fill removed? 0 Yes 0 No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO til Removed 0 Not Present ElOther <br /> FORMATION <br /> If not known,Indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> QNo Annular Space Exits <br /> 0 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(S) <br /> Grouting Materif4 eat Cern_ from _0 to R 5 ft. yards_l_____ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? 0 Yes 7 No <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 & Env. Services 136654 <br /> Contracfgr Business Name-. License or Registration No. <br /> \ t <br /> ----- 11/21/07 <br /> Authorized Representative Signature Date <br /> Richard Stevens <br /> LOCAL COPY H 115664 Name of Person Sealing Well or Boring <br /> HE-01434-02 <br /> 10/958 <br />