HomeMy WebLinkAboutWell & Boring sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSlin2170
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County Name
WELL AND BORING SEALING RECORD Minneso aoUnique Well No. �j
Minnesota Statutes,Chapter 1031 or W-series No.
P (Lame blank n-kn-n)
Township e Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed
l4 6 t/--Orono 11 a 172 1A % D 07
GPS Latitude degrees minutes seconds Depth Before Sealing 5111�& ft. Original Depth __ft.
LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
3505 Wayzata Blvd., Orono WELL/BORING —PeMeasured ❑Estimated Date Measured
Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or boring "'
in section grid with"X" location,showin property ❑Env.Bore Hole ❑Other _! ft. below El above land surface
N r 1 lines,r ds,a uildin CASINGTYPE(S)
--'--- --i-----`-----'-- tom✓ �-✓
�T I�wSteal ❑Plastic ❑Tile F]Other
\\\ :LjD'
WELLHEAD COMPLETION
WET ❑ �,I
Outside: Well House ❑At Grade Inside: Basement Offset
r /h Mile F-1Pitless Adapter/Unit E]Buried ❑Well Pit
uried
B
B
S ❑Well Pit ❑Other
1 Mile ❑Other
7M 7 RR RTA 185410
ME
f
141
PROPERTY OWNER'S NAME/COMPANY ACASING(S)
Dia eteir Depth r Set in oversize hole? Annular space initially grouted?
roperty owners mailing address if different than well location address indicated above in.from to + ft. LlI�Yes No Ll Yes ❑No ❑Unknown
Carl Bolander & Sons Company in.from to ft. E]Yes ,❑No ❑Yes ❑No ❑Unknown
251 Slarkey St
St Pau M 5510+ in.from to ft. ❑Yes [-]No El Yes [:]No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
f
Well owner's mailing address if different than property owner's address indicated above Screen from t0._� ft. Open Hole from to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL I COLOR HARDNESS OR
FORMATION FROM TO Obstructions removed? Kes ❑No Describe
PUMP
If not known,indicate estimated formation log from nearby well or boring. p
i Type Ile u M 17
1\r• LyidvRemoved ❑Not Pr sent ❑Other
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 Material/�/�6/if 4� ���irrom /,o_ toi ft yards--/Z 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 Wo 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.
Dori Stallb2a %11 Drilling Co.. Inc, 16%
Contractor Business Name License or Registration No.
erti red Pepresentative Signal Certified Rep.No. Date
21705
LOCAL COPY �"�
Name of Person Sealing Well or Boring
HE-01434-09 IC#140-0423 sosR