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MINNESOTA DEPARTMENT OF HEALTHMinnesota Well and Boring r 163486 <br /> WELL OR BORING LOCATION ling No. <br /> SeaH <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. r - — - <br /> Hennepin Minnesota Statutes, Chapter 1031 or W-series No. <br /> (Leave dank If not known) <br /> Township Name Township No. 'Range No Section No. Fraction Ism.-I Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 35 ti 7/19/00 NA <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Ge` l # <br /> Depth Before Sealing1 12 h. Original Depth eke <br /> 825 Old Long Lake Road, Wayzata g '� �b �\� <br /> Show exact location of well or boring Sketch map of well or boring AA�OUIFER(S) STATIC WATER LEVEL �� <br /> in section grid with"X". location, showing property `-T Single Aquifer ❑ Multiaquder <br /> lines,roads,and buildings �y`( <br /> N WELUBORING (^ Measured ❑ Estimated ' �V <br /> • (i r(ii 1 i f'�Water Supply Well ❑Monit.Well �73 N <br /> r , , , <br /> L_,:t <br /> `❑f'Env.Bore Hole ❑Other f h below ❑ above land surface <br /> W r--,----, E " CASING TYPE(S) <br /> i ( Steel ❑ Plastic ❑Tile ❑Other _ <br /> I I I I }ft mile <br /> 1__- CASING(S) <br /> '�'"'�� Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> It, r mire, 4 <br /> r' 2 in.from 0 to 108 tt. ❑ Yes 9 No ❑ Yes ❑No 171` Unknown <br /> PROPERTY OWNER'S NAME in.from . to ft. ❑ Yes ❑No ❑ Yes ❑ No yl Unknown <br /> Unknown <br /> Bruce Dayton <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> C/8 Larry Carlson SCREEN/OPEN HOLE <br /> 965 Old Long Lake Road Screen from 101 to 112 h. Open Hole from to ft. <br /> Wayzata, MN 55391 OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill 'Cl No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above Type of Obstructions(Describe) `�` <br /> Obstructions removed? ❑ Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed El Not Present CI Other <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 /> `yl No Annular Space Exists <br /> _- . ❑Annular space grouted with tremie pipe <br /> ❑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 Matenal Neat Cement from 0 to 112 ft. yards 7 e 5 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 `r✓t'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 /> ;t:svens Drilling & Env. Services. Inc. 86654 <br /> Contractor Business Name License or Registration No. <br /> , 7/21/00 <br /> Authorized Representative Signature Date <br /> Richard Stevens <br /> .'KCAL Co i- H 163486 Name of Person Sealing Well or Boring <br />