HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing H 107812
County Name WELL AND BORING SEALING RECORD to
Minnesota Uni ue No.
Minnesota Statutes,Chapter 1031 or W_,
Minnesota
Herne n (Leaveblan i oJC�1111
Township Name Township No. Range No. Section No. Fraction(sm.-).Ig.) Date Sealed Date Well or Boring Constructed
Orono 1177 9,; is
JAN 3 01997
Numerical Street Address or Fire Number and City of Well or Boring Location
Depth Before Sealing —ft. GIDITYEOF-CRONO—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 -Single Aquifer E] Multiaquifer
lines,roads,and buildings.
N WELLIBORING ❑ Measured ❑ Estimated
Water Supply Well ❑Monit.Well
❑ Env.Bore Hole ❑Other 7, —ft. below Elabove land surface
W --�- -�-- --�-- --i-- E CASING TYPE(S)
Steel E] Plastic E]Tile ❑Other
v mile
-I-- --�- -- -- --�-- CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
pIIy� S
mite 2"""��J��� A^f
t in.from to—� ft. ❑ Yes No ❑ Yes ❑ No Unknown
PROPERTY OWNER'S NAME in.from _ to— ft. ❑ Yes E] No No E] Yes ❑ No ❑ Unknown
Property owner's mailin s nt 'o dress indicated above. in.from to_ ft. ❑ Yes ❑ No ❑Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
225 Tonka Ave.
Screen from��to�� ft. Open Hole from to ft.
Orono, MN 55356 OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill- No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill
Obstruction/Debris/Fill removed? ❑ Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed E] Not Present E] 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:
�. No Annular Space Exits
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 Ne(I t _ iT�11 tom �— to 4)1— ft. yards 2 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 No
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.
c3biii Narilling & Env. e T v C e Wense n No.
Authorized Representative Signature t
dirk stevens
LOCAL COPY TH 107812
tlO7812 Name of Person Sealing Well or Boring
HE-01434-02
10/95R