Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring r <br /> WELL OR BORING LOCATIONSealing No. H 5 7 <br /> County Name _ WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes, Chapter 1031 or W-series No. <br /> Hennepin (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction Ism.-i Ig I Date Sealed Date Well or Boring Constructed <br /> Orono 127 23 04 ti ti <br /> Numerical Street Address or Fire Number and City of Well or Boring Location�t <br /> 405 S. Wi 12ov Drive Orono, M • Depth Before Sealing ft Original Depth _ ft <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". location, showing property ❑Single Aquifer ❑ Multiaquiter <br /> lines,roads,and b ildings. <br /> N { WELUBORING [I Measured El Estimated <br /> t� ❑-Water Supply Well ❑Mond Well <br /> --r- -,-- y © ❑ Env.Bore Hole ❑Other ft ❑ above land surface <br /> Lr ❑below <br /> W --�- -i-- - -- --i-- E CASING TYPE(S) <br /> --�- - - -i-- -- Steel ❑ Plastic ❑Tile ❑Other <br /> CASING <br /> 4— -i-- --1-- <br /> Diameter Depth Set m oversize hole'? Annualar space initially grouted? <br /> l S <br /> f mne f,., in.from to ft. ❑ Yes El, Yes E]No ❑ Unknown <br /> PROPERTY OWNER'S NAME 'r! in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Lake Associates <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 2354 W. Wayzata Blvd. SCREEWOPENHOLE <br /> Ste. D Screen from to ft Open Hole from to tt <br /> Long Lake, Mn. 55356 OBSTRUCTIONS <br /> WELL OWNER'S NAMEXo <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris dl ,f�oJ Obstruct ons. <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No La�scri68 <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> It rot known,indicate estimated formation log from nearby well or boring, <br /> ❑ No Annular Space Exists <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to tt. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> Grouting Material from to 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 ❑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 /> DON STODOLA WELL DRILLING CO. , INC. 27172 <br /> Contractor Business NarM` License or Registration No. <br /> r <br /> Authorized Representative Signature Date <br /> LOCAL COPY <br /> H 156792 Name of Person Sealing Well or Boring <br /> HE•01434-04 8/98 R <br />