HomeMy WebLinkAbout2004 - well & boring Sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 228583
County Name
WELL AND BORING SEALING RECORD M nnlenotao.Unique Well No.
'
HENNEPIN Minnesota Statutes,Chapter 1031 or W-series No.
( II not )
Township Name Township No. Range No. Section No. Fraction(sm-Ig) Date Sealed Date Well or Boring Constructed
ORONO 117N 23W 06 /9 OCT. 0
GPS Latitude degrees minutes seconds y^rte
I
LOCATION: Depth Before Sealing `-�} ft. Original Depth e� ft.
Longitude degrees minutes secondsIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer
WELL/BORING X1 Measured 0 Estimated
356 Lake Street W. Orono, Mn. water Supply Well 0 Monit.Well D
Show exact location of well or boring \ Sketch map of well or boring
in section grid with'X' `) location,showing property ❑Env.Bore Hole 0 Other ft. below 0 above land surface
•N ) lines,roads,and buildings. CASING TYPE(S)
a i (Steel 0 Plastic ❑Tile ❑Other
W- E'�
WELLHEAD COMPLETION
I Outside: 0 Well House Inside:�7f Basement Offset
I f I I *mils - 0 Pitless Adapter/Unit 0 Well Pit
1
S \ 0 Well Pit ❑Buried
116—r m.411h ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)T�i NPaO� �E$USE �UI j j'x Diameter Depth f Set in oversize hole? Annular space initially grouted?
Property owns s mai ing a dress'd eren an we oca ion a rens in oa ed above
3 in.fronO to J I ft. ❑Yes No ❑Yes 0 No ❑Unknown
4420 Shoreline Drive in.from to ft.
Spring Park, Mn. 55388338 ❑Yes 0 No 0 Yes 0 No 0 Unknown
in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 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.431 to S5 ft. Open Hole from to ft.
OBSTRUCTIONS
XRods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions(Describe),_I,Q /01 a ,,,,,..5:7---
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?X Yes 0 No Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP (/��
m
.A ij 'J .... TYPe ` l ut �f Removed ❑ Not Pr sent ❑Other
'METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�p No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal
/� in.from to ft. 0 Perforated 0 Removed
in.from to ft. 0 Perforated 0 Removed
Type of perforator
0 Other
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
+Ct ' r
Grouting Material I nom _to 83cft. 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? 0 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.
x
i
f DON STODOLA WELL DRILLING CO. , INC. 27172
Contractor Business Name4.fLicense or Registration No.
• o?:':+rg!�t a ignatu Date
.... LOCAL COPY H 228583
1- t.--• `,—
l i -� -,4a"�-_
Name of Person Sealing Well or Boring