HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 313286
Seal
County Name
WELL AND BORING SEALING RECORD Minnleso aoUnique Well No.
�iennepin Minnesota Statutes,Chapter 1031 or W serieskNo.
Township Name Township No. I Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 05 Sit SW SE // 7&AK 12
1
GPS Latitude degrees minutes seconds Depth Before Sealing /Q� ft. Original Depth _ft.
LOCATION: Longitude degrees minutes seconds
� L]UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Bon Location Single Aquifer Multiaquifer
760 TonkawR Rd, Orono 5535 WELL/BORING X Measured ❑Estimated Date Measured SAZrot 6AN
Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or boring �]
in section grid with"X° location,showing property ❑Env.Bore Hole L]Other _i1�ft. �below [j above land surface
N ``' lines,roads,and buildings. CASINGTYPE(S)
❑Steel XPlastic
-]Tile ❑Other
--i-----'------F--'--`' WELLHEAD COMPLETION
,
W E
Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
h Mile j *itless Adapter/Unit ❑Buried ❑Well Pit
T
--------------Iil_
❑well Pit ❑Buried
' s 71 Other
1 Mile ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Dia2jer Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailingaddress if different than well location address indicated above i1
y in.from to�U ft. Yes No Yes No
�f ❑ � ❑ ❑ ❑Unknown
P.O. Box 4W)726 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Blaine, Mn 55449
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
7 ��/ r
Well owner's mailing address if different than property owner's address indicated above Screen from��to ii ft. Open Hole from_ _to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check`Valve(s) ❑Debris/f ❑Fill El No Obstruction
Type of Obstructions(Describe) ..L/V/l/��Sf
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes E]No Describe
FORMATION
If not nown,indicate estimated formation log from nearby well or boring. PUMP
/ Tyne
llt7 Removed ❑Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
XNo 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
❑Other
GROUTING MATERIAL(S)�1 (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
T
Grouting Material /yL../� elleCJ/ from 40' to/j , 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 XNo How many?
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 Drilling CiI Inc. 1691
Licensee Business Name License or Registration No.
i epresentative Signaturr Certified
iRep.No. Date
LOCAL COPY H 313286
Name of Person Sealing Well or B®
ring
IC#140-0423 - 5/12R