HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I I 338231
County Name
WELL AND BORING SEALING RECORD MZnleso aoUnique Well No.
Nennepin Minnesota Statutes,Chapter 1031 or
aneries Noi.
Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 05 SK Sid SW 2-r7n-P
GPS LOCATION-decimal degrees(to four decimal places) Q op
Depth Before Sealing `� ft. Original Depth ft.
Latitude Longitude
A UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring LocationSingle Aquifer ElMultiaquifer6W Tonkaws Rd, orono /►,�y
L 7WELL/BORING Measured L]Estimated Date Measured Max [A
5 SS' Water-Supply Well El Monit.Well /
Show exact location of well or boring Sketch map of well ring
in section grid with"X" location,showinIn
Env.Bore Hole ❑Other Alft. below ❑above land surface
N lines,roads,and CASING TYPE(S)
\ _r Steel Ll Plastic ❑Tile ❑Other
WELLHEAD COMPLETION
W EI
Outside: ❑Well House ;!(At Grade Inside: ❑Basement Offset
%Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit AUG 0 8
T 1l ❑Buried
115111 �� _
❑Well Pit 2016
�1 Miley ❑Other ❑Other
CITY OF ORONO
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameteter,♦ • Depth ♦ Set in oversize hole? Annular space initially grouted?
Property owner's mai ing a dress if different than well location address indicated above in.from Q to 97 ft. ❑Yes )(No ❑Yes ❑No ❑Unknown
1700 Niagara Lane N in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Plymmth, MN 55447
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if different than property owner's address indicated above Screen from to-� _ft. Open Hole from to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris [-1Fill
/�❑No Obstruction
Type of Obstructions(Describe) &0#0 PIP—A f CM'u-iiI
GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? Ky.
s EJNo Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring. PUMP ,, •-
Type (t�[� Pt►M n
1� �✓ Removed ❑Not Pretent ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
loo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes o TN#
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Materjal,040!W 65<//6yll.from V to--'I'T— ft. yards bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes Xo How many?
�gy�� WaLICENSED OR REGISTERED CONTRACTOR CERTIFICATION
NIM: Old address for property s; This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
666 TonkaWa Rd, Orono is true to the best of my knowledge.
Don Stodola Well Drilling Co,. Inca 1691
Licensee Business Name License or Registration No.
,eertilied Representafive Signalbre Certified Rep.No. Date
�``` .�'
LOCAL COPY H 33323 Name of Person Sealing Well or Boring :1
HE-01434-14 ID#53159 5/13R