Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �Q���� <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique WeII No. `� <br /> Minnesota Statutes,Chapter 103/ or W-series No. <br /> (Leave blank il not known) <br /> Towns ip ame ownship No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono lI 3 '� �4t S6� <br /> ,� , ; <br /> �� GPS Latitude _,_.__, degrees _ minutes _ seconds Depth Before Sealing �� ft. Original Depth k. <br /> LOCATION: Longitude___ degrees_ _ minutes seconds ��FER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ' ingle Aquifer ❑Multiaquifer Q�y�M! 1�/1� <br /> � I�Bf �+�' ��Q�' � S�� 1yF�UBORWG �easured ❑Estimated Date Measured�����`r� �-�Y <br /> �:j�vater-Supply Well ❑MoniL Well <br /> Show exact location of well or boring Sketch map of well or boring ��/� <br /> in section grid with"X." location,showing property ❑Env.Bore Hole ❑Other � .� ft. �elow ❑above land surface <br /> lines,roads,and buildings. - <br /> N CASING TYPE(S) <br /> '�� --'-----'------`-----'-- ' . <br /> �Steel ❑Plastic ❑Tile ❑Other _ <br /> ; � I I �� �.;: <br /> --'-----�-----`-----'-- �' WELLHEAD COMPLETION <br /> W � � � � ET �/ <br /> ;.� ' ' ' ' I Outside: �]Well House ❑At Grade Inside: JlBasement Offset �i <br /> —-----------—--- — �I-'� <br /> � , , , r Mile rtless A p dUnd ❑Buried �f Well Pd <br /> �� ❑P' da te <br /> --�-----T—---�----�— [J <br /> I Buried <br /> 1��. ❑Well Pit � <br /> 5 <br /> ❑Other <br /> �—1 Mile� +�' ❑Othef <br /> PROP�R�O�ER'S NAME/COMPANY NAME CASING(S) <br /> � Dia�te�� �� Depth� �� Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if tliflerent than well location address indicated above in.from to ft. ❑Yes �1No ❑Yes _]No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes i]No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE� � <br /> Well owner's mailing address if diflerent ihan property owner's address indicated above Screen from +�1 to�ft. Open Hole from to ft. <br /> i <br /> OBSTRUCTIONS � <br /> �Rods/Drop Pipe ❑Check Valve(s) �Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)C.�<</_.�T � �rl✓/Ll�e�' / -�� ¢ �L � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [�es ❑No Describe •.�"'��'� �v f ��'/�tGi�I J • �' ~ � �s <br /> FORMATION <br /> PUMP <br /> If not own,indicate estimated formation log from nearby well or boring. <br /> Type <br /> ` � ��I`.Removed ot PreseM [;Other <br /> A1ETjdOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> dno 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 /> —I Other <br /> GROUTING MATERIAL(S) (One bag of cement=94�s.,one bag of bentonite=50 Ibs.) <br /> Grouting Material("���� �`//�/"�from � to �� 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,DIFPICULTIES IN SEALING Other unsealed and unused well or boring on property? �__J Yes [� lo 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 <br /> is true to the best of my knowledge. <br /> � Don Stodola �ell IIcilling Co,. Inc. 1691 <br /> Licensee Business Name - � License or Registration No. <br /> /J- � - O �'! <br /> i e enta�e i atur� Certilied Rep.No. Date * <br /> '. •.. ��--�+ �, ` <br /> LOGNL COPY H f�Y Z 1 i.ri. —____ _ _— --- �`�'�3�V�. +�`"t'\`.l <br /> Name of Person Sealing Well or o�ing � <br /> HE-01434-11 IC#140-0423 �� 2ioaa <br /> �r.... .. .... ....:�-,.R, ,;��:*� ....,..:�,�.�. -- � -<-,,:._� .� ��.�� _ - - - <br />