Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 3 6 2 7 5 /� <br /> WELL'OR BORING LOCATION WELL AND BORING SEALING RECORD sealing No. H �t <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W series No. <br /> Hennepin (Leave bk il not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 03 NW NE IN i/451/8 <br /> GPS LOCATION-decimal degrees(to four decimal places) 4, <br /> Depth at Time of Sealing 97 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 25 n= ' Rd S' o � WELL/BORINGMeasured Date Measured SA/1mL LIQ r ❑Estimated <br /> D v Water-Supply Well ❑Env.Well _ e <br /> Show exact location of well or boring Sketch map of well or ring <br /> in section grid with"X" location,showing prop ty ❑ /S Temp.Env.Well ❑Other ' ft. Kbelow ❑above land surface <br /> lines,roads,and buildit s. <br /> N CASING TYPE(S) <br /> *tee! ❑Plastic ❑Tile El Other <br /> ---1--- --i------F------'--- rz t WELLHEAD COMPLETION <br /> W ET �— <br /> ;___ +___ -+ Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset <br /> Mile ` <br /> iaW Well Pit ❑Buried ❑Well House <br /> ---I------ - --- <br /> ❑Well Pit <br /> . _ ❑Other <br /> 3 <br /> ❑Buried <br /> 1 Mile _..... <br /> El Other <br /> ~' <br /> For multiple temporary environmental wells,provide ad al location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter" � / Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNERS NAME/COMPANY NAME / i'it <br /> n.from_40__ Yes a_ to 53 ft. ❑ �INo ❑Yes]\ ❑No ❑Unknown <br /> WojAVAPPIRetaktaddress indicated above <br /> in.from to ft. ❑Yes ❑Na ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> r , <br /> Screen from 93 to 17ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> OBSTRUCTIONS <br /> Well owners mailing address if different than property owners address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill Jo Obstruction <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe _, <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. A Type <br /> If <br /> .1 C'-/ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> 1��� /f[ l I X No Annular Space Exists El Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> UCasing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement- 4 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material�� T�' _'� 'rom_egt._ to___51 ft. yards$__ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes XNo How many? _ <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> rim todoin Well Drilling ('.o, . Inc- 1691 <br /> Licensee Business Name .1„ License or Registration No. <br /> AppripA i <br /> i!'� 1 I - / o -/8 <br /> Ce ed-epr en �-'- ' Ar-a ' Certified Rep.No. Date <br /> ct,,*,„ <br /> LOCAL COPY " 3 6 2 7 5 4Name of Person Sealing Well or Bo'q '41.4.-~r"N. <br /> HE-01434-16 ID#53159 9t1711 <br />