HomeMy WebLinkAboutwell & boring sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring "ling No. 243236
County Name
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Hennepin Minnesota Statutes,Chapter 1031 or W-series No.
(Leave Monk a not ab.
Township Name Township No. Range No. Section No. Fraction(sm-e•Ig) Date Sealed Date Well or Boring Constructed
QBlow 117 23 05 23-0027 'A r C- 05
GPS Latitude degrees minutes secondseo
LOCATION: Depth Before Sealing ft. Original Depth ft.
Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location 'Mingle Aquifer 0 Multiaquifer
389
Westlake St, OLS 55356 [)WELLJBORING easured 0 Estimated
(Vater Supply Well 0 Monit.Well ,
Show exact location of well or boring Sketch map of well or..'ng
in section grid with"X" I. . .. 0 Env.Bore Hole 0 Other ft. ,slow 0 above land surface
Ines, •ads,and buildin,s.
N • CASING TYPE(S)
•
k
sySteei 0 Plastic ❑Tile 0 Other
W---r---,- --,-- , E WELLHEAD COMPLETION
I
Outside: Well House Inside: 0 Basement Offset
Y
1 1 I I frtmr
Z! 0 Pitless AdapterlUnil ❑Well Pit
1 i— i t I
0 Well Pit ElBuried
Ir'—r milt--4 ,y5C1 0 Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
PobPrt Rricksnri Diameter Depth t Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it different than well location address indicated above
�,.!__ 2. In.from d to (� ft. ❑Yes �No ❑Yes ❑No 0 Unknown
600 Twelve Oaks Center Dr in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown
Ste 654
Wayzata, MN 55391 in.from to ft. 0 Yes ❑No 0 Yes 0 No ❑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 '/C f to Q o f ft. Open Hole from to ft.
OBSTRUCTIONS
p(Rods/Drop Pipe 0 Check Valve(s) 0 Debrisb0 Fill 0 No Obstruction
Type of Obstructions(Describe) 3 f)/ /'"fr.4 o C"Nx ziU 9-e
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? f, es CI No Describe
FORMATION T
If not known,indicate estimated formation log from nearby well or boring PUMP
Type '--I Akin Pi)M 1'
drift 0 80 (Removed ❑ Not Present 0 Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
'No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal
]/�� in.from to ft. ❑ Perforated 0 Removed
in.from to ft. 0 Perforated El Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material " ' "7 f J?Tom U'
N4O to AO 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? 0 Yes lI o 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 License or Registration No.
� ....110r.- 12-15-05
A-"onir.Representative Signat. - Date
LOCAL COPY H
243236 Jim Antonson
Name ofPerson Sealing Well or Boring