HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ���0�t� �
WELLOR BORING LOCAT�ON �yELL AND BORING SEALING RECORD sea���9 No. i H._ L
counry Name Minnesota Uni que Well No. � -- �
HENNEPIN M�nnesota Statutes.Chapter 1031 or W-series No.
h.ew awc rc na tnown�
Townshlp Name Township No. Range No Section No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Constructed
EXCELSIOR ��7 23 21 ��• SE� NW Wednesday,August 23,2000
Numerical Street Atldress or Rre Number and City oi Well w 0onng Loca6on 139
2700 SHADYWOOD ROAD Deptn Beto�P sea���q _—n o�igina�oeptn _n
Show exact locahon of N•ell or boring Sketch map ol well or bonog AOUIFER(S) STATIC WATER LEVEL
in section grid wtlh"X'. location, showing properly �Single Aywfer ❑ MWtiaquRer
lines,roads,and bwldinqs.
N w �. WELUBORING �Measured ❑ Estimated
§
�Water Supply Well ❑Monit.Well �f
I I - -- � � � Env.Bo�e Hole ❑Other _ GO R. �below ❑ above land surtace
, , gar qe
W '"�- - - -�-- - E CASING TYPE�S)
' v garane Black T8�C
, � � � �
—�- -;-- -i-- --�-- � ro �Steel ❑ Plastic �Tile �Other
� � � �
Yzmile ':`µ�/��'` CASING S
__�_ _i__ _�__ __i__ � ( J
shadtns�ood road Diameter Depth Set m oversrze hole? Annular space initially grouted?
� S 3 0 139 ves (3jNo ❑ ❑ ❑
t mxe� in.from to ft. ❑ Yes No Unknown
PROPERTV OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
NICOLLS,WILLIAM H.
Properry owner's maihng address ii diHerem than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ UnknOwn
2700 SHADYWOOD ROAD SCREEWOPEN HOLE
EXCELSIOR,MN 55331-9599 Screen+ror� �39 ro e open Ho�e trom to n.
oesraucnoNs
WELL OWNER'S NAME Rods/Dro Pi e
� p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's meiling aAdreu if tlifierent than property owner's atltlress mtlicated above. Type of Obstructions(Describe) Removed 63�X�.Z�J��Drop Pipe 8 Jet Packer...
Obstructions removed? [g Yes ❑ No Describe
PUMP
TYPQ Prior Removed Deep Well Jet Pump...
6EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
�- If rat krawn,indicete estimated formatbn log from nearby well or bonng. METMOD USED TO SEAL�ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE:
iO.ivo Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑ Pertoreted ❑ Rertroved
in.from to ft. ❑ PeAorated ❑ Removed
Type of peAorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.)
Neat Cmt p .3 0.00054
Grouting Material from to fl. yards bags
Enviroplug .3 139 0.24966
from to ft. yards bags
�
irom to ft. yerds bags
from to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER W ELLS AND BORINGS
WEII LOC8t2fJ I!1 PU�YIP ROO�Y1 O�SOUtII SICIe Of B0S2R12(lY... Other unsealed and unused well or boring on property? ❑Yes �No How many?
� LICENSED OR REGISTERED CONTRACTOR CEHTIFICATION
Measured From Top Of Casing....
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.
Removed Cement&Drop Pipe From Well Prior To Sealing... Ma1211k@ W8t2f 763.493.3650 27600
Contractor Business Name �License a Registretion ivo.
M ron Malenke � /:`�� , u ust 23, 2000
y :�'`��' ;l�.� {– �'`f�:�'��
2� 117 23 24 0031 Authorized Representative Signature t Dare
.�G�� ,"�J�y; u �/��O�/� Name ol Person Sealing Well a Bonng
�, o L