Well info - Laserfiche WebLink

Home Browse Search

i WEL!OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H '1 "j ) County Name WE�L AlVD BORING SEALlNG RECORD Mnnle9oaoUniqueWellNo. ) H e n n e p i n Minnesota Statutes,Chapter 1031 or W-series No. � ��a�o�,�;,�o,.��m, Township Name Township No. Range No. Sectior,No- Fraction(sm.�Ig.) Da1e Sealed Date Well or Boring Constructed Orono 1 1 7 23 22 'u �4 NU� 10-21 -08 . GPS Latitude � degrees_ minutes._ seconds Depth Before Sealing 18 4 fl. Original Dep1h �l_ LOCATION: Longitude degrees_ minutes seconds AOUIFER(S) STATIC WATER LEVEL Numerlcal Street.4ddress or Fire Number and Ciry of Well or Bonng Location Xl Single Aquiter G MWtiaquifer 7�� B i g I s 1 a n d � �r�n� � WELVBOfiING [�Measured ❑Estimaled Date Measured � ��Waier-Supply Weil :_`_i Monit.Well Show exact locahon of well or boring Sketch map of v�ell or boring �, 'in section grid with"X" location,showing properry ❑Env.Bore Hole `,Ofher ��ft. �below U above land surtace -� � lines,roads,and buildings. CASING TYPE(S) N _"_'_ "_�" ""_''_"'"' . �j Steel ❑Plastic iJ Tile ❑Other � � � � -� WELLHEAD COMPLETION W ; ; � � ET - _.;.__ ' ' ____y_. Outside: ��]Well House i�A1 Grade Inside: I_'�...Basement Otfse� � , � � 'h Milo II Pi ' ' ❑Pilless AdapledUnii ❑Buried �i_i We 't --:-----r-----.- ---:- 1 ,� � Well Pit ❑Buried , 5 � , � ❑Other �--i M�ie—� ❑Other PROPERTY OWNE S NAM /COMPANY NAME CASING(S) � B r i a n �3 o t�i a m Dia�eter G Depth� O O Set in oversize hole? Annular space initiaily grouted7 Pmperty ov+n[!rs mailing adtlress II tlitferent Ihan weli location adtl�ess Intlicated above � � in.irom U to U fL �Yes [�No �Yes ❑No ❑Unknown 387 Margaret Circle W a y z a t a , M N 5 5 3 91 ___��.��om_ �o___ft. ❑ve5 �.�No ❑Yes ,:�No r_��k�oW� _in.Irom . to_ _tt. ❑Yes _!No ❑Yes ❑Plo ❑Unknov✓n I WELL OWNER'S NAf�1E/COAdPAiJY�JAME SC�SEcN/OPcN HOLE Same 1p/� Well owner's.nailin^y aCdross�il�il;erent II-�,-,n pr�pyrty p�=;r.er s adUress inC�iw�ed above �Cl2?�irom�Q____IG__LV�} f;. Oeen HCIe 1fGT.___ to ft. OBSTRUC710NS �X;aedslDrop Pipe ��Check Vaive{s) ❑Debns '. F��II ;No Obstructior. T,-Fe�f obs«��;,o�s,oes��,be, 1 Y4" D r o p_�p e & p a c k e r j e t GEOLOGICAL PdATcRIAL COLOR I HARDNESS OF I FflOfvi� TO Obslrudions remov=_d?x�(Yes J�No DescribA � I FORtr1ATION � I -{PU�:1P II not!cnev.�^,,inCiCate e5limated iormalion log`rom nearbv riell or borr,g. r. . e+ C Typ2 U� t, C 1 a y y� w M e d � 4`� Xi Removed '�;Not Present I—,Olher II — —_____— --- � I 4 5 I O ��THOD USEDTO SEAL ANNULAR SPACE BETWtc�2 CASINGS,UR CASING AND BORE HOLE: ��Mu Annular Space cxis;s �_i Annular Space urouted�.vith Tr2mie ripe ��_j Casin PerlorationiR?moval Clay , Sand Grey Med � 80 , 13 - 9 I i � ---------.in.irom_------ to__. _1L !_j Pzrforated J'.Removed Sand Gra � Soft 136 180 ` I . —_____ in.from ________�o__ .ft. f_)periorated I._j Removed � Npe of Periorator _----- ------ '^�;Oth��_ _ � GROUTING MATERIAL(5) (One 6ag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material_��']__S_Q 1 1 � trom�j to�_�� ft. __ yards__�_ bags & Bentonite from to__ ft. _ yards bags irom to ft. yards bags OTHER WELLS AND BORINGS REIviARKS,SOURCE OF DATA,DIFFICULTIES IM SEALING Other unsealed and unused well or bonng on property? ❑Yes �j No How many^ G e o 1 o t a k e n f r o m n e w �^f e 1 l 0 n LICENSED OR REGISTERED CONTRACTOR CERTIF!CATION 9 Y This wali or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report S i 't e . is true to the best of my knowledge. M N U I V Q # 4 614 7 0 Co c or Busines N n C� Llcense or R g toion N�o. _ 1101 Certilied Representative Signature Certified Rep.No. Date H � ° � Ron Danielson 10-21 -08 :�i'JiV '� . 'i UF N�-_. TH r�:iP'/ �;��i �� -- Name ol Person Sealing Well or Boring HE-01434-09 IC#740-0423 fi106R I