HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 108122
County Name
WELL AND BORING SEALING RECORD Sealing
Minnesota
Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-t.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 17 31-003 1- (-_
Numerical Street Address or Fire Number and City of Well or Boring Location r
If
3785 Togo Rd VSA/ Jh77� 55391 Depth Before Sealing �j� ft. Original Depth sz 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, showing property [)4ingle Aquifer ❑ Multiaquifer
lines,roads,app buildings.
N / :fi- j� v WELL/BORING >(1Aeasured E] Estimated
ater Supply Well ❑Mont.Well
{1 i
Env.Bore Hole El Other
ft. 'below Elabove land surface
W --�----�-- 0--�-- --�-- E ( ( } CASING TYPE(S)
' ff �
t
---- ----- --�-- --�-- i + Steel ❑ Plastic ❑Tile ❑Other
Mile
CASING
Diameter Depth '
Set in oversize hole? Annualar space initially grouted?
t mile T 'in.from </ to � ft. ❑ Yes tVmo ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME in.from _ to tt. ❑ Yes No ❑ Yes ❑No ❑ Unknown
Paul Rimachendorfer 471-9014
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
r
Screen from to ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME
Obstruction El Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill 446. iiiie �' f �iV"✓t
Obstruction/Debris/Fill removed? 15<Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed XNot Present ❑ Other
FORMATION
If 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
f
❑ 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 4 —S,L— to ft. 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.
Don Stodola Well DrilliriL Co., Inn. 27172
Contractor Business Name / License or Registration No.
ho R Asenfg-t,v Signature. Date
LOCAL COPY H
10812 -2 Name of Person Sealing Well or Boring
HE-01434-02 10/95R