HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring l
County Name
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
HENNEPIN p Leave blank down)
Township me Township No. Range No. Section No. Fraction ism->Ig) Date Sealed Date Well or Boring Constructed
/aLoo C) 117 23 07 Ver' 5C Friday,December 19,2003
GPS Latitude degrees minutes seconds
LOCATION: Depth Before Sealing 220 ft. Original Depth CWi-III record ft.
Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Fill
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ElMultiaquifer CFND
1345 VINE PLACE WELUBORING [Measured El Estimated
[X Water Supply Well ❑MOnlf.Well
Show exact location of well or boring Sketch map of well or boring / ��n� /
in section grid with"X" location,showing property [:]Env.Bore Hole E]Other 50 ft. below above land s?12 0S
N lines,roads,and buildings. CASING TYPES) _
4'x 220'weft 0110)VO
E]Steel Plastic E]Tile E]Other Plastic
-�- -;-- -;-- --;-- f?--�'- WELLHEAD COMPLETION
W E
�{ — Outside: ❑Well House Inside: ❑Basement Offset
j4mie glraye > �_Pitless Adapter/Unit ❑Well Pit
m ❑Well Pit ❑Buried
S
--1.0. " ! ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
DAVIS.MARGARET M. Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it different than well location address indicated above
4_ in.from 0 t0 215 ft. ❑Yes ❑No E]Yes ❑No E]Unknown
1345 VINE PLACE
" in.from to ft. ❑Yes ❑No E]Yes ❑No E]Unknown
MOUND,MN 55364
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 215 to 226 ft. Open Hole from t0 ft.
SAME OBSTRUCTIONS
LX Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) Removed 75'X 1.00"Poly Drop Pipe And Submersible Pump...
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM FORMATION TO Obstructions removed? Yes ❑ No Describe
If not known,indicate estimated formation log from nearby well or boring PUMP
Clay Type Sibinerisle Prunp
Removed ❑ Not Present ❑Other
Sand(Fine) 65 170 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
Clay 170 205 EX No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
Sand 205
216 in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Drilled-1984
Depth-4"X 216 Type of perforator
Screen-212-216' ❑ Other
Static Water-
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material Neat Cement from—_5 to—5..5—ft._0.001-6 yards bags
Enviroplug from 5 Al to 220 - , 0 6864 yards bags
from to yards bags
GEOLOGY FROM: 4 NORTH$ E DR OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No Ho any?
w comer of house LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
pitless adapter located 20'nw
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.;-he information contained in this report is
well depth measured from grade level true to the best of my knowledge. i
mdh staff was not on site during well sealing Myr L 111111aierdue!Lialimillim Water (763)493.3650. 27600
Contractor Business Name / ense or Registration No,
verification of notification was received from mdh
j.
M.L.MalerAce
D eoerriber 19,2003
07 117 23 42 0004 Authorized Representative Signature ate
LOCAL COPY H 216339 Name of Person Sealing Well or Boring