HomeMy WebLinkAboutwell & boring sealing record WELL OR BORING LOCATION Sealing
DEPARTMENT OF HEALTH Minnesota Well and Boring H 24'4235
Sealing No.
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin �.wblank Mnot ,
Township Name Township No. Range No. Section No. Fraction(sm-ii.Ig) Date Sealed Date Well or Boring Constructed
Orono 117 23 05 23-0042 Z,. b EC (:•)S�
GPS Latitude degrees minutes seconds r
LOCATION: Depth Before Sealing 8 9 ft. Original Depth ft.
Longitude degrees minutes seconds AO IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer
ELL/BORING y Measured ❑Estimated
365Westlake St, Orono 5 ater Supply Well 0 Monit.Well r
Showexact location of well or boring etcn map of well or boring
in section grid with"X' m.Bore Hole ❑Other 4.,5 ft. Xbelow 0 above land surface
linen ds,-enibuildir gs..
N err CASING TYPE(S)
'-r--- -�- --'--r-'
Steel IDPlastic ❑Tile 0 Other
W E WELLHEAD COMPLETION
1 1 1
a}' Outside: 0 Well House Inside: 0 Basement Offset
1 I I I
1mrj ❑Pitless Adapter/Unit ❑Well Pit
39-A 0 Well Pit 0 Buried
S
-r"'+'- ' \ ..g Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)C
Rel-ort Rrf rksnn 952-475-31n2 Diameter r Depth r Set In oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above 7 J I'S
in.from i 2 O- to ft. 0 Yes >I No 0 Yes ❑No ❑Unknown
600 Twelve Oaks Center Dr
Ste 654 in.from to ft. 0 Yes 0 No 0 Yes ❑No ❑Unknown
Wayzata, MM 55391 in.from to ft. ❑Yes ❑No ❑Yes ❑No 0 Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
y/�� ,I /
Well owners mailing address if different than property owners address indicated above Screen from `••�_ to _q___ft. Open Hole from to ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe 0 Check Valve(s) 0 Debris ❑ Fill X No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0 Yes 0 No Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
drift 0 Type
❑ Removed ' Not Present 0 Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
yjNo Annular Space Exists 0 Annular space grouted with tremie pipe 0 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.)
M _ /, p
Grouting Material N�rr176479/44-",from Vr to eq 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 !/ •
to 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 Name `
fLicense or Registration No.
s /(' 12-15-05
."... -'7prese S..t•= •naty.= Date
LOCAL COPY
H 243235Jim Antonson
Name of Person Sealing Well or Boring