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Home My WebLink Aboutwell info wELL OR BORING LOCA7iON MINNESOTA OEPARTMENT OF HFALTH M�nnesota Well and Bonng I H �� WELL AND BORING SEALING RECORD Menne oNa Unique No. Counry Name � � ; Minnesota Statutes.Chapter 7031 or W-series No. Hc n t1 r�p i n ILeave biank A not Nnown� Township Name Township No. Range No. Section No. FracOon(sm.-►Ig� Date Sealed Date Well or Boring Consiructea ' �rono I17 23 7 , ,. 6/29j99 Numencal CStreet Address o�Fire Number and Gry of Well or Bonng location �,�(��7 R�$t. �O.L Il t. Roa d OL Qrl� Depth Betore Seahng 1 5 N. Onglnal Depth �`� n Show exact location of N�ell or boring Sketch map of well or bor�ng AOUIFER(S) STATIC WATER LEVEL in section grid with`X`. � /{� location, s�owmg pioperty �Single Aywfer ❑ Multiaquifer -r � lines,�oads,and b ildi s. N WELUBORING �Measured ❑ Eshmated �Water Supply Well ❑Monit.Well ❑ Env.Bore Hole ❑Other _ dr 1� R. ❑below ❑ above land surface W "�' -�-- -�"- --�-' E CASING TYPE�S) � � � � � � � —�- -�-- -i— --�-- � �Steel ❑ Plastic �Tile � Other u mde ... � �� , . � CASING -�-- -�{-- --�— � � � Dlameter Depth Set in oversrze hole� Annualar space initially grouted? S _-- l ��m;�� ti � �_ m.trom� to 1 a fl. ❑ Yes �No ❑ Yes ❑No ❑ Unknown i PROPERTY OWNER'S NAME in.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown �v�iid 01sc�n Property owner's maihng address if diHereN than well loca6on adtlress Indicated above in.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown SCREEWOPEN HOLE Sc�een irom 1� to x� ft. Open Hole from to R. OBSTRUCTIONS WELL OWNER'S NAME Rods/Dro Pi e � p p ❑ Check Valve(s) ❑Debris ❑Fill �No Obstruction Well owner's meHing address it diHerent it�en properry owner's adtlress indicated above. Type Ot ObstruCtions(Describ6) Obstructions removed? ❑Yes ❑ No Describe PUMP Type OEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Ll Not Present ❑ Other FORMATION METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: It rat known,inditete estimated fortnatbn log irom nearDy well or bonng. � 15 �No Annular Space Exists �� ❑ Annular space grouted with tremie pipe � ❑ Casing Perforation/Removal in.from to ft. ❑ PeAorated ❑ Removed in.from to fl. ❑ PeAorated ❑ Removed Type ot peAorator ❑ Omer GROUTING MATERIAL(S) GroutingMatenal ��rtl�l�d from �'� to � R. yards � bags from to R. yards bags irom to ft. yards begs from to_— ft. yards begs REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WEILS AND BORINGS Other unsealed and unused well or boring on property7 ❑Yes �J No How many? LICENSEO OR REGISTERED CONTRACTOR CERTFICATION This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The infortnation contained in this report is true to the best of my knowledge. �E� Wzll 8ri�liuy �7�i� Contredor Business Name- ;'s^�� Licerrse a Rejis rio. � •/`` " S/ G'.�,.'�^i�'L: �� e:vw ..G.i � w Authorized Representative Signature Dete .. _, _ Ja�er� L�a � �-� ! `--:�� :�c �t�-: : ' Name ol Person Sealing Well a Bodng LOCALCOPY HE-01434-04 8�98 R WELL OR BORING LOCATiON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � —� WELL AND BORING SEALING RECORD Sealing No I H �,�,�,� ,� � �j' ` Couny Name Minneso!a Unique No. Ht'{1Fl�ci'�lYi Mmnesota Statutes,Chapter 1031 or W-series No. � (Leave bla�k if nol known) � Township Name Township No. Range No Section No. Frachon�sm.-s Ig.) Date Sealed Date Well or Boring Constructetl � Orono 117 `l3 7 ,, ; 6/29/99 Numencal Street Address or Fire Number and Ciry of Well or Bonng Location i l 1405 R�ast Poi�t Roflsi Orono Depth Betore Sealing j Z N_ Original Depth j� n� Show exact locanon of�•ell or boring } Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL in section grid wdh"X'. A � � locafion, showmg property �Smgle AyuAer ❑ Multiaquifer ,� � lines,roads,and buildin s. N U WELUBORING � Measured ❑ Eshmated �]Water Supply Well ❑Monit.Well v ❑ Env.Bore Hole ❑Other _ drj tt. ❑below ❑ above land suAace W --�- -�-- - -- --�-- E CASING TYPE(S) � � � � . —�- -r- -i-- --�-- � � �]Steel ❑ Plastic ❑Tile � Other � , � � �mrle V ' ' ' ' I �` CASING —�- -i-- -i-- --�-- � Diameter Depth Set in oversize hole? qnnualar space indially grouted7 S � � fl ❑ � L _ �m;�� _ in Irom to Yes No ❑ Yes ❑No ❑ Unknown r� PROPERTV OWNER'S NAME in.trom to fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown Property owner's mailing address B OiHerent than well loca6on adtlress indicated above. in.from to tt. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE Screen from � to j L ft. Open Hole from to R. OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Vatve(s) ❑ Debris ❑ Fill [�Mlo Obstruction � Well owners maNirp address A diHarent Man properry owner's address indicated above. Type of ObstruCtiOns(DesCribe) Obstructions removed? ❑Yes ❑ No Describe PUMP Type (iEOlO(i1CAL MATERIAL COLOH HARDNESS OF FROM TO � Removed (�Not Present ❑ Other FORMATION N rat krawn,indicete estimeted formatbn lop from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � No Annular Space Exists dr i f t � 12 ❑ Annular space grouted with tremie pipe � ❑ Casing Perforation/Removal in.trom to ft. ❑ Pertorated ❑ Removed in.from to it. ❑ PeAorated ❑ Remrned Type ot peAorator ❑ otner GROUTING MATERIAL(S) GroutingMaterial ��rt3'��ld from �'l ro v fl. yards � begs from to R. yards bags from to ft. yerds begs from to-- ft. ya�ds begs : REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS Olher unsealed and unused well or boring on property? ❑Yes �rvo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The infortnation contained in this repoA ia true to the best of my knowledge. R�5 we33 Drilliny 1�� Contractor Business Name License w Registra' fvo. ,:1�� ==�`-,-�/' '' �� AuMorized Representative Signefure Dat James i.�a Name ol Person Sealing Well a Boring � LOCALCOPY H HE-01434-04 8/98 R