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HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 20650 County Name Sealing No. 1 WELL AND BORING SEALING RECORD Minnesota Minnesota Unique Well No. Hennepin Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank it nol known) Township Name Township No. Range No. Section No. Fraction Ism�Ig) Date Sealed Date Well or Boring Constructed Orono 117 23 21 .23-003 /7 GPS Latitude degrees minutes seconds Sr� LOCATION: Depth Before Sealing "-' ft. Original Depth V ft. Longitude degrees minutes seconds p IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer 2702 Halters Port Lane, 'Orono W'E!/JBORING Measured ❑ Estimated 7(Water Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring 757 in section grid with"X' location,showing property E] Env.Bore Hole E]Other ft. below E]above land surface N �_ ,} lines,roads,and buildings. CASING TYPE(S) �V\\' XSteel ❑Plastic ❑Tile ❑Other W --�- - -------------- E WELLHEAD COMPLETION , Outside: Well House Inside: E]Basement Offset l4mtb - (itess Adapter/Unit E]Well Pit 1 \ ❑Well Pit ❑Buried S �1 r""t° ` - ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Andrew McDe rmo952-471-9898 Diame �� Depth Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above (, in.from to �-R. ❑Yes XNo E]Yes ❑No [j Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑ No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r r Well owner s mailing address if different than property owner's address indicated above Screen from ,.L to—35,5 ft. Open Hole from t0 ft. OBSTRUCTIONS ods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Type of Obstructions(Describe) J; A.162 /27- /eU/�� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑ No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring . � Type 5 c)(�; 6)j?`]n Removed ❑ Not Present ❑ Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �tNo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal J� 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.) i Grouting Material Ale/1 T ft. yards _2�L 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 X No 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 Co. , Inc. 27172 Contractor Business ame License or Registration No. A hori d Representative Signature Date OCAL COPY H 2 0 6 5 0 1 ✓ Name of Person Sealing Well or Baring �'