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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �73 / 8i <br /> WELL OR BORING LOCATION <br /> County Name -- Sealing No.WELL AND BORING SEALING RECORD Minnesota Unique Well No. 1- - { <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin (Leave dank x not known) <br /> Township Name I Township No. Range No Section No. Fraction Ism.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 4 k i4 <br /> 11/6/00 . <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 790 S Old Crystal Bay Rd, OronoDepth Before Sealing 104 _ ft Original Depth 104 it <br /> Show exact location of well or boring 0 t Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X" location, showing property X Single Aquifer ❑ Mulhaqurter <br /> lines,roads.and buildings. <br /> N WELL/BORING "Measured ❑ Estimated <br /> I $�Water Supply Well ❑Monit.Well G ,-v� <br /> r , , , J �0)( (( ❑ Env.Bore Hole ❑Other 51 ft. LXoelow ❑ above land surface <br /> W---r----1----i-----n--E `{J�' <br /> `1iL CASING TYPE(S) <br /> ---�--------i--,--A--- T .Steel ❑ Plastic ❑Tile ❑ Other <br /> ' I I kmi <br /> +--H 1--- iCASING(S) <br /> 'PE. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> LLL S qJJ'� , <br /> µ t mile <br /> in.from to 10 ft. ❑ Yes X No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Arthur Blair <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from 100 to 104 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME yf! Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris Fill ❑Jet <br /> Obstruction <br /> Well owner's mailing address if different Than property owner's address indicated above Type of Obstructions(Describe) Pump, Pipe, u e t & Tank <br /> Obstructions removed? "Yes ❑ No Describe <br /> PUMP <br /> ��Tyype Jet <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO yf�Removed ❑ Not Present ElOther <br /> FORMATION <br /> If not known,indicate estimated fonnatan log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ItNo Annular Space Exists <br /> Drift 0 104 <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. 0 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 Portland from 104 to 0 ft. yards 4 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 OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes "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 /> &ES Well Drilling 27276 <br /> Contractor Business Name License or Registration No. <br /> 4 :Authonz <br /> Reprissentative Signature Date <br /> James Lea <br /> LOCAL COPY H 173781 Name of Person Sealing Well or Boring y <br />