Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> 188f <br /> WELL AND BORING SEALING RECORD Sealing H o <br /> County Name Minnesottao Unique Well No. � -- <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> - <br /> (L—Nl X-known) L_ <br /> Township Name Township No. Range No Section No. Fraction Ism.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 31-0022 A10 v 15 <br /> Numerical Street Address or Fire Number and City of Well or 55391 <br /> ggyLoocation r <br /> 3760 60 1 ogo Rd. Orono 5 l3T 1 Depth Before Sealing ft Original Depth �� It <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" lucallorl, snowingerty Single Aquifer ❑ Multiagwfer <br /> hoads,and butldi s. [:] Estimated <br /> WELL/BORING Measured <br /> Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other _ _ —_.ZC.a ft. [Xelow ❑ above land surface <br /> W --_ _i__ -_ E f- <br /> -- <br /> CASING TVPE(S) <br /> --i --� - Y eel ❑ Plastic ❑Tile ❑ Other <br /> Yz mile <br /> u-- -,-- --�-- <br /> CASING(S) <br /> Diameter f�, Depth Set in oversize hole? Annular space initially grouted? <br /> LLLLS ! {'► I <br /> lY�r milegr in.from r+ _ to fl. [j Yes LOA ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME !` in.from to It ❑ Yes ❑j No ❑ Yes ❑ No ❑ Unknown <br /> tr r <br /> Property own s mailing address if different than well location address indicated above infrom to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from—X0 to �` , ft Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe p E] Check Valve(s) ❑ Debris ❑ Fill YNo 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 El Removed )< Not Present ❑ Other <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boning. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> io Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to h. ❑ Perforated ❑ Removed <br /> in.from to h. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL($) ,(OO�ne bag of <br /> cement=94 lbs.,one bagofbentonite=50 lbs.) f <br /> Grouting Material <'� A'' from —0lo Ile) /ft. yards �[_ 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 *o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIrICATION <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 /> Don Stodola Well Drilling Co- � Inc 2_Z17.2 <br /> Contractor Business Nam �: License or Registration Pro. <br /> 11-19-99 <br /> uthon epresental Signature - Date <br /> Jim Antonson <br /> LOCAL COPY JH 161880 Name of Person Sealing Well or Boring <br />