Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H 20658?_ <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnlesotta Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leflv2 blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction Ism i Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 2-0020 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing S -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 ❑Multiaquifer ��,,!!'' <br /> WELL/BORING Measured E]Estimated <br /> [)/ater Supply Well E]Monit.Well /` <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X' to ti n,showinQ�P�operty E] Env.Bore Hole E:1Other _ft. Xbelow ❑above land surface <br /> N /t lin os,,,�ndb�^ings. CASING TYPE(S) <br /> 7 feel ❑ Plastic ❑Tile ❑Other <br /> t <br /> xL WELLHEAD COMPLETION <br /> Outside: Well House Inside: <br /> ❑ ❑Basement Offset <br /> )4mile ❑PitessAdapter/Unit Nell Pit <br /> ❑Well Pit ❑Buried <br /> S <br /> r mea <br /> ❑ Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> BobDPieper Diameter Depth f Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above ��� / <br /> in.from to 1 C1 ft. ❑Yes )<No ❑Yes ❑No ❑Unknown <br /> 2 of in.from to ft. El Yes !!�❑El No E]Yes E] No E]Unknown <br /> L in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> VI � r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill [RAo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> drift 0 50 Type <br /> —— --— ❑ Removed CNot Present [IOther <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 MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> �yy r <br /> Grouting Material NI/'�/�4rome_toft. 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? es ❑ 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 Dri i l inZ Co, . incl ?71 72_ <br /> Contractor Business Name License o' egistratron No. <br /> ,j 5-12-03 <br /> A ori e e nt ri vE Sr natur_ Date <br /> /� /� <br /> n I'► Jim Antonson <br /> LOCAL COPY H 2 0 6 5 8 L Name of Person Sealing Well or Boring <br />