HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 113025
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No.
County Name Minnesota Unique No.
p�i'•'(� Minnesota Statutes,Chapter 1031 or W-series No.
H�Y (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.->Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 17 31-<)034, G 9�
Numerical Street Address or Fire Number and City of Well or Boring Location
3545 Togo Rd, Orono 55391 Depth Before Sealing Z ft. Original Depth r ft.
Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X". -- location, show}ne property Sin le Aquifer
;i Iin6lii�s(�r1i buildings g q E] Multiaquifer
N WELUBORING Measured ❑ Estimated
i
ater Supply Well ❑Mont.Well
❑ Env.Bore Hole ❑Other 2GZ—ft. �elow ❑ above land surface
yy --�- -�-- --�-- --;-- E CASING TYPE(S)
i
-'�- -�-- ------ --j--- feel ❑ Plastic ❑Tile ❑Other
-- --�-- --�-- --�-- CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
t md. __._..-.. in.from to?/1 ft. ❑ Yes N Vo E] Yes E]No E] Unknown
PROPERTY OWNER'S NAME in.from to ft. E]Yes '❑ No ❑ Yes ❑ No ❑ Unknown
T)arWn Car1sco 471—8111
Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑No ❑ Unknown
SCREEN/OPEN HOLE
Screen from� to ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction �/f}j^��'[' 7�
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill -Z (UA,411 / L.!-'< 4' 4 `.!
Obstruction/Debris/Fill removed? X11
es ❑ No
PUMP 1�
Type �/�T 117W
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other
FORMATION
It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
XNo Annular Space Exits
l
❑ Annular space grouted with tremie pipe
(� ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other —
GROUTING MATERIAL(S)
Grouting Material 4e
44Z"_47; ��� to fL yards bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes XNo
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
Dw Stodola Well Orillin�, Co., I1.4c. 27172
Contractor Business Name License or Registration No.
u1 i,,e t Representative Signature Date
Name of Person S I{ngWell or Boring ted,
LOCAL COPY H 113025
HE-01434-02
10/95R