HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTN Minnesota Well and Boring ���0�� —�
WE«oR BOR�N��o�AT�oN _ WELL AND BORING SEALING RECORD Sealing No. q i H
Counry Name Minnesota Uni ue Well No. r--- --
HENNEPIN Minnesota Statutes. Chapter 103� or W-series No. �— �
ti.ew u�x�o�wmwn�
Township Name Townsh�p No. Range No Section No Fraction(sm.-►Iq.) Date Sealed Date Well or Boring Constructetl
ORONO 117 23 17 ��.SE �.NW�,. Wednesday,September 06,2000
Numencal Street Address or Fhe Number and CRy of Well or Bonng Locahon 55
1875 SHADYWOOD ROAD Depth Before Sealing_ __R Original Depth __n
Show exact locafion of K-ell or bonng Sketch map of weli or bonng AOUIFER(S) STATIC WATER LEVEL
in section grid with"X". Iocation, showing property �Single Aywfer ❑ Mulfiaqurter
Gnes,roads, tl buildings. �,,c,
N I WELUBORING iJ Measured ❑ Esumated
g]Water Supply Well ❑Monit.Well
,`�e ❑ Env.Bore Hole ❑Other _ _30 tt. C� below ❑ above land surtace
W --�- - -i-- --'-- E '--- CASING TYPE�S)
' � � ' a
� � � Galvanized T&C
-;-- -'--
_�__ __�__ haus o s�eei ❑ Plastic ❑r�ie ❑ o�ne�
}1 mile p�
' ' ' ' � o CASING(S)
-�-- -�-- -�-- --i--
' a Diameter Depth Set in oversize hole? Annular space initially grouted7
re
�r mxe� `�I 2 in.irom 0 to 55 tt. ❑ Yes �] No ❑ �es ❑No ❑ Unknown
PROPERTY OWNER'S NAME { in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
TILLOTSON,GLEN
Property owner's mailmg address if ditterent ihan well location adtlress indlcated above. in.from to ft. ❑ �es ❑No ❑ �es ❑No ❑ Unknown
1875 SHADYWOOD ROAD SCREEWOPEN HOLE
ORONO,MN 55391 Screen from 55 to ft Open Hole from ro ft.
OBSTRUCTIONS
. . WELL OWNER'S NAME �] Fods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Weil owners mailing address if difierent than properry owner's address inGicated above. Type of Obstruc�ions(Describe) REfT10VeCJ 4Z'X 1.25"Drop Pipe&Jet Packer...
Obsiructions removed? �Yes ❑ No Describe
PUMP
TYPe Deep Well Jet Pump...
GEOL061CAL MATERIAL COLOR HARDNESS OF FROM 70 � Removed ❑ Not Present ❑ Other
FORMATION
It rat krawn,indicate estimated formatbn log from nearDy well or bonng. �METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
TJ No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to n. ❑ Pertorated ❑ Removed
in.from to h. ❑ PeAorated ❑ Removed
Type of perforator
❑ otner
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=SO lbs.)
Neat Cmt 3 3.5 0.0004
Grouting Material from to it. yarOs bags
Enviroplug 3•5 55 0.0412
from to R. yards bags
�
from to ft. yerds begs
trom to_ fl. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Well Located In Backfilled Well Pit On West Side Of House... oine�unseaied and u�used Weu or bor�ny on Property? ❑ves �]No How many?
� � '� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
Measured From Grade Level...
� This well or boring was sealed in accordance wiM Minnesota Fules,Chapter 4725. The information contained in Mis repoR is
true to Ihe best of my knowleAge.
Malenke Water 763.493.3650 27600
i�Y �}f V a'i s_. ..,� Conhactor Business Name J License a Registretlon I'io.
/
Myron Malenke ,,�`, ` �;:•- ! ,, September 06, 2000
17 117' 23 24 ���2 Authonzed Representative Signature Dete
.. I_.1�1`�a:. ,,,�c.�y p�,k u A ��� j� Name o/Person Sealing Well or Bonng
r� 1 t�