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Home My WebLink Aboutwell info Minnesota Well and Boring WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 41370 County Name WELL AND BORING SEALING RECORD Minnesota Unique No. � Minnesota Statutes, Chapter 103/ or W-series No. =1eY�^� in (Leave blank,f not ku—nl Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Approximate Date Well or Boring Constructed a a t Numerical Street Address or Fire Number and City of Well or Boring Location _ t �. _ Depth Before Sealing �� ft. Original Depth � �� it " . t Show exact location of well or boring Sketch map of well or onn9 Static Water Level XAccurate in section grid with"X`. location,showing propert lines. roads.and buil ings. ❑Approximate N Single Aquifer ❑Multiaquifer fL below above land styrface CASING TYPE W E mite _. Steel ❑Plastic ❑Tile ❑Other S �- Screen from to .� it Open Hole from to ft. N I mire -►I 3 OBSTRUCTION/DEBRIS/FILL _ PROPERTY OWNER'S NAME ;KObsiructlon ❑Debris ❑Fill Mi ke J�,fflll �"� 6��"� Type of debris/obstruction Ok �� l�lY'�� l=�=�• p- �f�� Mailing Address If different than property address indicated above. 7.,,., Obstruction/Debris/Fill removed? es El No `� �'uGt-t Hare PUMP J 'I"i Fair[ Lake Stxe..e+- ❑Removed Not Present ❑ Other _. 1 :i7 CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? If not knownindicate estimated formation log from nearby well or boring. t � 1 drift 0 1 S- in.from to ft ❑Yes ;fo ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ,,M----,E//THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �qNo Annular Space Exists //❑``Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to IL ❑Perforated ❑Removed MType of perforator ❑Other GROUTING MATERIAL Grouting material r .Z1'd 7 LX f7rt 4,"`k .ffrom _40� to ' ft, yards bags from to ft, yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to ft, yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes XN. 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 5tc Bola well Drilling Co. , Inc Z71,72 Contractor Business Name License or Registration No. ArGThoozed Rer � •' presentative Slgnaturrf ate LOCAL.COPYI I Jim Antoris )n Name of Person Sealing Well or Boring HE-01434-01 - --, MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring +� �j WELL OR BORING LOCATION Sealing No. �H_ 3 County Name WELL AND BORING SEALING RECORD Minnesota unique well No. L� — 96 Hennepin Minnesota Statutes,Chapter 1031 or W-series No. (Leave Clerk M not krawn) Township Name Township No. Range No Section No. Fraction ism -i Ig.) Date Sealed Date Well or Boring Constructed Orono 11.3 23 31 31-0,005 /8 04:f7-- 61 Numerical Street Address or Fire Number and City of Well or Boring Location { 385 Turnham Rd, Orono 55359 Depth Before Sealing ft Original Depth Show exact location of well or boring Sketch map of well of boring A_O)JIFER(S) STATIC WATER LEVEL in section grid with"X'. location, showing p ^Single Aquifer ❑ Multiaqulfer lines,roads,and buil ngs N WE/LUBORING Measured [I Estimated +� /Water Supply WeII ❑Monit.Well h �/ ❑ Env Bore Hole ❑Other ft. ij�below ❑ above land surface W -- - - -- 'i'" '-�-- E CASING TYPE(S) - - -- -i-- --�-- �\ Steel ❑ Plastic ❑Tile ❑ Other }Amite CASING(S) Diameter Depth Set in oversize hole? Annular space initially grouted? S Z .> �L -1 mile in.from 4 to—5K�— If. ❑ Yes No ❑ Yes ❑No ❑ Unknown PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown Charles Phelps Property owner's mailing address if different than well location address indicated above. infrom to If. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE t0 / 6 Screen from_ �to_1_ !. ft. Open Hole from to ft. OBSTRUCTIONS WELL OWNER'S NAME Rods/Drop Pipe ❑Check Vallvve�(s)) ❑ Debris /❑ Fill ❑ No Obstruction /}7- /�(� Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) Lam+/ 1 /'-tJ� e 1466/w6"-T Obstructions removed? k.s ❑ No Describe PUMP Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed X, Not Present ❑ Other FORMATION If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: driftf No Annular Space Exists U r i.`t ❑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) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) //� 0.-�-'-' Grouting Material �!W7- ��%"'" m � to 11..�e 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 OTHER WELLS AND BORINGS 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. Fon 8todola Well Drillin, Co, Inc. 27172 ContractoZB�usiness me License or Registration l'ro. r - 10-18-0 ofho resentaffve Signature Date Jim Antonson H /1/1 Name of Person Sealing Well or Boring LOCAL COPSE BMJ!L1