HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��� !�n —_�
EL�OR BORING LOCATION I
���N Name — WELL AND BORING SEALING RECORD Sealing No. �H +cf 3
Minnesota Unique Well No. r
H����i� Mmnesota Sfatutes.Chapter 1031 or W-series No. II J
�Laeve daiNc X nd kmwn) L_
Township Name Township No. Range No Sechon No. FracUon(sm.i Ig.) Date Sealed Date Well or Bonng Constructed
�'QTi� �.�+� �� 2� ,. ,.
Numerical Street Address or Fi�e Number and Gry of Well or Bonng Locauon t ^s
28Q5 bth Ave. North, LOl2� �r$�� Depth Before Sealing j�i N Original Depth ft
i Show exact location of v.�ell or bonng `Sketch map of well or boring ApUIFER�S) STATIC WATER IEVEL
in section gnd wrth"X". location, showing property �ingle Aywfer � Multiaqwfer
i lines,roads,and buildings.
ry WELUBORING �Measuretl ❑ Estimated
i � � � � �Water Supply Well ❑Monit Well
—�- -i— --;-- —� p�
. ❑ Env.Bore Hole ❑Other q!.—ft. [�below ❑ above land surface
(„�:; . w -�- -i-- -i— --;— E CASING TYPE�S)
� � , �
�� -;-- -i-- --;-- --�— � [�Steel ❑ Plastic �Tile ❑Other
}4mile
—`- ---- -�— --�-- � CASING(S)
Diameter Depth Set in oversize hole? Annular space initially grouted?
S
�I(.--i m��e��'. � in trom� ro 1�� tt ❑ Yes �No ❑ ves ❑No (�Unknown
PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
P�operty ownei s mailing address if different than well location address Indicated above in.from to ft. ❑ Ye5 ❑ No ❑ Yes ❑No ❑ Unknown
- �,�5� V.t� AD'�. ATb.L•�h SCREEWOPEN HOLE *
LiG.�'Qg��-.�i�� � >.lJJ6 Screen from ��� to j�� ft. Open Hole from to tt.
OBSTRUCTIONS
WELL OWNER'S NAME
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction
Well owner's mailing address it CiBerent than properry owner's atldress indicated above. Type of ObstruCtions(Describe) �
Obstrudions removed? ❑Yes ❑ No Describe
PUMP
Type
QEOL061CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
� FORMATION �
If not known,iMicate estimated tortnation log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
L7No Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to h. ❑ Perforaled ❑ Removed
in.from �o ry, ❑ Perforated ❑ Removed
��- Type of perforator
❑ other
GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=501bs.)
- Grouting Material �8gt C'���� from � to 1�7 R. yards �� bags
S
from to R. yards bags
from to ft. yards bags
- from to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes �,.J No How many?
� UCENSED OR RECa1STERED CONTRACTOR CERTIFICATION �
This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is �'
true to the best of my knowledge.
Stevena Drilli�g � 8nv. Serv�.ces. Inc, 8fi654
� Contractor Business Name ' �" License a Registrahon I'a.
�����
Authorized Representative Signature Dete
Rs.ndy 3ohnsa� ol/�s1U�
H 16 3 4 5 3 Name ol Person Sealing Well or Boring
__......._., . _.......,....,. ._„ ��
� . . .... .. . .
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wF�l QWNER AND ADDRE86 —'
- �l� - �� I B?��� �' � �,J� � • WELL RKORD ,
WELL LOCAT�ON
3ECTION LOT �
e�ocec VILLAGE OF ORONO
� DRILLER'8 816N T /tE CRYSTAL BAY, MINN. .
DATE
PERMIT NUMHER
" LLING COMPANY !U-IA'7� � �.�
ADDRE88 � - � -
�e/ /� TELEPMONE
�' �� I'�Zi�1 U��' ZS%/
31ZE OF WgL�� INCHES WATER LEVEI�.�Sf
FEET �
WELL DEPTH S � _FEET DRAW DOWN o �/,�
FEET AL � �_GPM i
CASING DEPTH � 7 O _FEET CAPACITY GALLONS�__
�U� PER/HR.
" DEPTFI OF IMPERVIOUS FORMATION
FEET CASED WITH
SCREEN_�_FEET�_�NCHES/BY �" WELDED JOINT ❑ :
MAKE AND TYpE MATERIAL: �—�NCHES ;
IREM.ARKB: _ ������ � fGQ,,j SCREWED JOINT❑ ;
(OV[R)
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TNICKNCff -
STARTED ENDED O/
KIND OF FORMATION COLOR DEPTH DEPTH /ORMA710r+ REMARKS
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1
EXTERIOR BPACE AROUND CASING SEALED WITH: � CEMENT GROUT � PUDOLED CLAY � OTHER
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D161NFECTANT UYED �
HOURS LEFT IN WEL�
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