HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' `"� '`� � � o
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MinnesoNa Unique Well No. �p `�� �� �
County Name
Minnesota Statutes,Cha ter f037 or W-series No.
t�enrte�in p ,�ea�e b�a�k�,�o,k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
OrOnO 117 2� 21 ST� � ?+�rT �
GPS LOCATION— decimal degrees(to four decimal places) /
Depth Before Sealing �j� ft. Original Depth fl.
Latitude Longitude
A�UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �[�� /►�/
L1C .7 n W LUBORING �Measured ❑Estimated Date Measured�p„�` �!`i f
�C?1 J .�lat+� , �i� IJrOT�� Water-Supply Well ❑Monit Well f (
Show exact location ot well or boring Sketch map of well or b �o ,Env.Bore Hole `�
in section grid with"X:' location,showing prope yb� ❑Other �ft. �elow ❑above land surface
N ' � S� CASINGTYPE(S)
��: --'---—i--—`-- ---'-- ??�� � �,/
= j j j j � � � I XSteel ❑Plastic ❑Tile ❑Other
� ��
-- —----- ---- ----- `' WELLHEAD COMPLETION
'- ' - ` t
W ' ' ' ' ET , i d IIH G d I d tOff t
� _ �_ _ �_____;__ __�__ I �,}utsi e: ❑We ouse ❑At ra e nsi e: �asemen se
'h nniie � ❑Pitless AdaptedUnit ❑Buried ❑Well Pit
` --:-- r----- :-- 1
�� � ❑Buried
' S `\` ❑Well Pit
❑Other
F—i Miie—� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameter t Depth � Set in over���si_z,,,///e hole? Annular space initially grouted?
Properry owner's mailing ad ess if ditterent ihan well location address indicated above ��n.from�`�" _ t0��,ft. ❑Yes �o ❑Yes ❑No ❑Unknown
2C16 it�rth Chestnut in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Chasks�, �rnl 5531�
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
��'* ^"� � n �
Well owner's mailing address if diHerent ihan property owner's address indicated above Scfeen ffom�L+�to_�[�_ft. Open Hole ffOm to ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
N ��r� .T'` �
Type of Obstructions(Describe) y4 /l� �' /
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? Yes ❑No Describe
FORMATION
PUMP
If no[known,indicate estimated formation log from nearby well or boring. ��r �u M�
a Type
D �� �Removed [�Not Present ❑Other
= �M,E`T'HOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�yrvo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforalion/Removal �
/�
in.from _to ft. ❑Perforated ]Removed
_in.from to ft. ❑Perforated ]Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material�U���//iL from�_ to?r� �ft. yards� bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No How many?
UCENSED OR REGISTERED CONTRACTOR CERTIFICATION �
R���I��� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
�?c�n �talola ��jell Drillin�; Co,.Inc. 1f�91
JUN 0 3 2 p�6 Licensee Business Name License or Registration No.
CITY OF ORONO �- l '�� - I Co --
i prASentative�gnat Certilied Rep.No. Date
� ;
_ •
" � ���8 2 .` �"`.�.,-.�. `
LOCAL COPY oe Name of Person Sealing Well or Bor'g
HE-01434-14 ID#53159 ' / 5/13R