Laserfiche WebLink
• <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I0 V V <br /> WELL OR BORING LOCATION Sealing No. H 170073 <br /> County Name — WELL AND BORING SEALING RECORD Minnesota Unique Well No. -- - -- <br /> Hennepin Minnesota Statutes,Chapter 1031 or W--se„es No. <br /> (Leave Donk Township Name Township No. Range No Section No. Fraction(sm.-►Ig) Date Sealed ,Date Well or Boring Constructed <br /> Orono 117 23 05 23-0043 2.1 R co " ` . <br /> • <br /> Numencal Street Address or Fire Number and City of Well or Boring Location /�� / kr .g� <br /> 364 V -Lake St, Orono Depth Before Sealing /O0 ft. Original Depth /Ai ,_ Coq <br /> Show exact location of well or boring Sketch map of well ori11 AOUIFER(S) •STATIC WATER LEVEL Cl <br /> 0 <br /> in section grid with"X". location, showing ope Ingle Aquifer ❑ Multiagwler C Y 2000 <br /> lines,roads,and bhlon \/ t✓h\ <br /> N ELL/BORING J�Measured ❑ Estimated U coqq� <br /> Water Supply Well ❑Monit.Well , rYO <br /> Td l l <br /> ❑ Env.Bore Hole ❑Other ';2, ft. below ❑ above land surface <br /> ---r---1----1-----�--^ CASING TYPES) <br /> 11 <br /> W l i E <br /> --l-----I----i--^---I--- p Steel ❑ Plastic ❑Tile ❑ Other <br /> I • I I I �` <br /> ___,____+___1 -1--- , �i )\ CASING(S) <br /> ,✓ %S Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> t mire �'' t• r� in.Irom Q to %I ft. 7 <br /> ❑ Yes (�No ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME <br /> 4 <br /> 4`v� in.from to ft. ❑ Yes ❑iNo 0 Yes 0 No ❑ Unknown <br /> Doi owner i& f o pYes No Unknown <br /> Pro owner ailin a ress i i Brent than well location address indicated above. in.from to ft. ❑ Yes ❑ No 0 ❑ ❑ <br /> 11401 Cty Rd 3 SCREEN/OPEN HOLE, , <br /> Hopkins, MN 45343 Screen from 9Co to l•©a ft. Open Hole from to ft. <br /> OBSTRUCTIONS • <br /> WELL OWNER'S NAME KRods/Dro Pipe <br /> 2 of 3 P P 0 Check Valve(s) ❑ Debris 0 Fill <br /> Li No Obstruction <br /> Well owner's mailing address it different than property owner's address indicated above. Type of Obstructions(Describe) � K ¢ POMP <br /> Obstructions removed? XYes 0 No Describe' <br /> PUMP �A <br /> Type Uer ''POM 4• 1,.- <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO lif Removed CINot Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> METHOD USED TO-SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> drift to Annular Space Exists <br /> Annular space grouted with tremie pipe • <br /> ❑Casing Perforation/Removal <br /> in.from to ft. 0 Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated 0 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��Jl��� from to /a O ft. yards —JI= bags <br /> from to ft. yards bags <br /> from to h. 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 /> • Do®°Stodbll` Well Drilling Co., Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> 8-22-00 <br /> -whop-,. se"live Sign:4 - Date <br /> Jim Antoneon <br /> LOCAL COPY- . H 170073 Name of Person Sealing Well or Boring <br />