HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnes�ota Well and Boring ir �(,���� �
WELL AND BORING SEALING RECORD Mennlesota Unique Weil No. I H `�
Gounry Name --
^^ Minnesota StaNtes.Chap�ei 1031 or W-series No. � �
xeiJ)ie ��"i h.eave aenk tt na known)
Township Name Township No. Range No Secuon No. Fract�on�sm.-s Ig) Date Sealed Date Well or Borirg Construaetl
Orono l 17 23 1 T �• �� /t� !�r�..� r�J'
Numencal Street Address w Flre Number and Ciry of Well or Bonng Location
/ / f �
� /L� ShadyMood Rd• ��Q��) ��• Depth Before Seahng ��lC _N. Original Depth . f/l ri
Show exact locatwn of v.•ell or bormg Sketch map of uCell qvp nng OUIFER(S) STATIC WATER LEVEL
in section grid wrth"X'. . .. . IocaLon, showing)¢roperty Single Aywter ❑ Mulhaquder
lines,roads,and buildings.
N �, . WELL/BORING �Measured ❑ Estimated
(�Water Supply Well ❑Monit.Well !
�❑~Ern.Bo�e Hole ❑Other ��_ft. �below ❑ above land suAace
T�
W -�- -�-- -;— --;-- E . ... CASING TVPE(S)
� � � � ,
� � �
� � �
-�-- -�-- -i-- --i-- � � . � �Steel � Plastic �Tile � Other
Yzmila �._._—n.+ - —
� � � + ; ..__. ( )
-�-- -i-- -� - --i— � � CASING S
� Diamete�r Depth � Set in oversize hole7 Annular space initially grouted?
S i t'l m.trom� to� fl. ❑ �es �No ❑ Yes ❑No ❑ Unknown
�I mHe �
PROPERTY OWNEF'S NAME � . in.from to fl. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown
Property owner's mailmg aAdress B�itterem than well locauon address ind�cated above. m.hom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
9J6�41�.'�'OGS� SCREEWOPENHOLE
� /� !
Screen from_���to__1_1',G ft. Open Hole from ro ft.
OBSTRUCTIONS
WELL OWNER'S NAME [�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailin atldress if tliHereN than ro e owner's address indicated above. �Jr.�) �
9 P P M Type of Obstructions(Describe)���},(��y����f f �'�/`�� g- ����l�l�%f����
arH�b 82 tte=•/RQ��� Obstructions removed? es ❑ No Describe
/0 1 J
FAX 952-475-801� PUMP N
TyPe "`(�t-'-�` f-~�a!r"a��t f`
GEOLOGICAL MATEHIAL COLOR MARDNESS OF FROM TO �emoved ❑ Not Present ❑ Other
�. FORMATION
� If not known,indicate estimated tortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� y �o Annular Space Exists
' f �,�'' ❑Annular space grouted with tremie pipe
, .
❑Casing Perforation/Removal
in.from to ft. ❑ Pertorated ❑ Removed
in.from �o n. ❑ PeAorated ❑ Removed
Type of peAorator
❑ Other
GROUTING MATERIAL(S) �One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
GroutingMatenal r+l�',!-�/ , '� �irom �` ro � �= ft. f
yards � bags
from to ft. yards bags
from to R. yards bags
irom to_ R. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes o How many?
LICENSED OR REGISTEREO CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this report is
true to the best of my knowledge.
I�ON STODOLA 6�ELL DRILLIN�' CCt. , IIV�. 27'172
Contiactor Business Name License or Registretion hJo.
s
.. - ��F _- .�� . ' = . a
x•
AYfuthopi"ed Representative Signature Date
- . . . d_ _ , �`r/
H ��J ��� Name ol Person Sealing Well or Bonng
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