HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSeang No. H
237125
County Name
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Hennepin
Minnesota Statutes,Chapter 1031 or W-series No.
Ltennepin (Leave Wank -k—)
Township Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed
Orono 117 23 04 1,".3 .-
GPS Latitude degrees minutes seconds
LOCATION: Depth Before Sealing /� ft. Original Depth 17A[tet ff.
Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer ❑Multiaquifer u
C L WELLBORING XMeasured E] Estimated
2845 Watertown Rd. Orono 55356 Water Supply Well [j Mond.Well
Show exact location of well or boring Sketch map of well or boring 1112
'
in section grid with"X" location,showing property E] Env.Bore Hole [:]Other V ft. Ybelow ❑above land surface
N - j I fts,roads,and buil fngk
CASING TYPE(S)
Steel ❑Plastic ❑Tile ❑Other
-�- -�-- -;-- --,-- WELLHEAD COMPLETION
W E
p Outside: ❑Well House Inside: ❑Basement Offset
limas t+, Pitless Adapter/Unit ❑Well Pit
2. ❑Well Pit ❑Buried
S
❑Buried
P P�jRTY O 'S N MP A /fit CASING(S)
lar , 5-1017 Diameter Depth r Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above
7085 Shady Oak Rd in.from d to 174 ft. ❑Yes XNo ❑Yes ❑No ❑Unknown
Eden Prairie, PET 55344 in.from t0 ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown
in.from t0 ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
r
Well owner's mailing address if different than property owners address indicated above Screen from t0 ._ft. Open Hole from to ft.
OBSTRUCTIONS
*X Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) _7_A.J fJ/-A f- JOtJe"42
GEOLOGICAL MATERIAL TCOLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑ NO Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
Type �L4� L)A
Removed ❑ Not Present ❑Other
i
i+ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No 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) (One bag of cement 94 lbs.,one bag of bentonite=50 lbs.)
Grouting Matenal f(,// T C-f!L'1� A.Z from 0 to 1-2p_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 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.
Dan Stodola Telell Drilling Co, Inc. 27172
Contractor Business Name License or Registration No.
o d t?Wrese"f9iv6 Signature Date
LOCAL COPY �H237125 Name of Person Sealing Well or Boring