Laserfiche WebLink
WELL OR BORIN(iLOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I 247520 <br /> County Name <br /> WELL AND BORING SEALING RECORD sM a.lin ota Unique Well No. <br /> Pepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> saws blank c not crawl <br /> Township Name Township No. Range No. Section No. Fraction(sm-)...Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 42 ZI J iv U(.0 <br /> GPS Latitude degrees minutes seconds r <br /> LOCATION: Depth Before Sealing /9 7 ft. Original Depth ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location (Single Aquifer 0 Multiaqulfer <br /> WELL/BORING ' XMeasured 0 Estimated <br /> 1230 Woodhill Ave, Orono 55391 Water Supply Well 0 Montt.Well <br /> Show exact location of well or boring Sketch map of well or boring �^ r <br /> in section grid with"X" location,showing property 0 Env.Bore Hole 0 Other 7._.C? ft. *low 0 above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> l teel ❑Plastic 0 Tile 0 Other <br /> W---r---i----1------1---E WELLHEAD COMPLETION <br /> { Q' <br /> JJ T}I Outside: 0 Well House Inside: Basement Offset <br /> -f-`-1----1 l--' I 'r— <br /> I I { I *metal 0 Pitless Adapter/Unit 0 Well Pit <br /> 0 Well Pit 0 Buried <br /> S <br /> li.—r^".--ill" ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> C.J.+( j ]/Jfusy Diam�e/ter r Depth Set in oversize hole? Annular space initially grouted? <br /> Property owners marl gad re if different than well location address indicated above / /! "+ <br /> in.from (� to / '7",)ft. ❑Yes �fJo 0 Yes 0 No 0 Unknown <br /> same as above in.from to ft. 7� <br /> ❑Yes ❑No 0 Yes 0 No 0 Unknown <br /> in.from to ft. ❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> /� ��7^ I <br /> Well owner's mailing address if different than property owner's address indicated above Screen from /`7 U to / �J ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill ><No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? El Yes 0 No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> y J / ❑ Removed C3.Not Present 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> AVo Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> 51e <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 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/(/4/9/ t" 91f.U/from to 7ti1 tX yards /ee, bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS { <br /> \ <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? 0 Yes ! o 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 Busine Name License or Registration No. <br /> Aul senestive Srnaturi <br /> 247520 g " Date <br /> LOCAL COPY H !c' ` ,s <br /> Name of Person Sealing Well or Boring / <br />