Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H205704 <br /> WELL AND BORING SEALING RECORD Minnlesotta Unique Well No. <br /> County Name — <br /> Hennpein Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank II not known) <br /> Township Name Township No. Range No. Section No. Fraction Ism-)-.Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 20 314-0001 <br /> GPS Latitude degrees minutes seconds n <br /> LOCATION: Depth Before Sealing ft. Original Depth– <br /> Longitude <br /> epth 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 ❑Multiaquifer <br /> 3035 Casco Pt Rd, Orono 55391 WELUBORINGeasured E]Estimated <br /> iNater Supply Well E]Mont.Well / <br /> Show exact location of well or boring ring <br /> in section grid with"X" location,showing prop rty E] Env.Bore Hole C]Other ft. below ❑above land surface <br /> N lines,roads,and buildi gs. CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - -- - -- -- -- E WELLHEAD COMPLETION <br /> �{ Outside: ❑Well House Inside: ❑Basement Offset <br /> Yemib ❑PitessAdapter/Unit IZwell Pit <br /> 4- <br /> 1 D 1 P ❑Well Pit E]Buried <br /> I\A ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> 95?-471-7204 Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above I' y� <br /> in.from (111) t0 ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREENIOPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from ZZ-R to_W.!7 t. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) ��j,( 4+- �A/M® <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?FORMATION es El No Describe <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> / <br /> ❑ Removed of Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIIIA/L(S)D/} (One bag of ccement== / <br /> 94 Ibs.,once bag of bentonite=50 lbs.) <br /> Grouting Material r,t/'�(y 7 C"!2 1f•/�}Z eO to 11.2 ft yards _ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 /> Contractor Business me License or Registrati�oryn c <br /> Afrher—eserii5rva Signatdre. �t[ , Date <br /> LOCAL COPY H q n;I n di ' �•. � <br /> Name of Person Sealing W0 or Boring <br />