HomeMy WebLinkAboutWell/Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 124608
WELL AND BORING SEALING RECORD Sealing H
County Name Minnesota
Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
Henne in (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-3.-Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 23 34 % � _`F��
Numerical Street Address or Fire Number and City of Well or Boring Location / , f
@XXX Wayzata Blvd, Orono Depth Before Sealing 217 /'7 ft. Original Depth 21/7 ft.
Show exact location of well or boring Sketch map of well or ioring �UIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing pr perry Single Aquifer ❑ Multiaquifer
lines,roads,and build i gs. >(
N WELUBORING J,3 Measured ❑ Estimated
Water Supply Well ❑Monit.Well
❑ Env.Bore Hole ❑Other =✓/
7 ft. below ❑ above land surface
W -� -� -� -' E CASING TYPE(S)
r
- -- - -- -�-- --�-- Steel ❑ Plastic ❑Tile ❑Other
_j__ - CASING
�^ z Diameter Depth Set in oversize hole? ?
�;',/d. � '4 t�/>f ! P � Annualar space initially grouted
—L in.from to��,� ft. ❑ Yes XNo ❑ Yes ❑No ❑ Unknown
L] E] E]O ERTY OWN 'S NAME in.from to . Yes No ❑ Yes No ❑ Unknown
Rft
ePbers Construction
Property owner's mailing address if different than well location address indicated above. in.from _ to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
3525 Webster Ave S SCREEN/OPEN HOLE
St Louis Park MN 55416
Screen from to ft. Open Hole from �` ll': to 2r"
920-6996 > ft.
OBSTRUCTIOWDEBRIS/FILL
WELL OWNER'S NAME
❑ Obstruction ❑ Debri:; ❑ Fill No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris'Fill
Obstruction/Debris/Fill removed? ❑ Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
A No Annular Space Exit
p El Annular space grouted with tremie pipe
p l a t v i l l e 218 247- ❑ Casing Perforation/Removal
in,from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
Grouting Material N��7! �� f�om G to /J ft. yards <�- bags
from to ft. yards bags
from to h. yards bags
from to_ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
r
Other unsealed well or boring on property? ❑ Yes No
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 Drillin6 Co. , Inc. 27172
Contractor Business
.,,Name License or Registration No.
7-10-97
Authorized Representative Signature Date
im Antonson
LOCAL COPY TH 124608 [Name of Person Sealing Well or Boring
HE-01434-02 10/95A