HomeMy WebLinkAbout2002 - well and boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 1 9/�Q/1 8
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. H j, [,Q[,
County Name Minnesota Unique Well No.
Hennepin Minnesota Statutes,Chapter 1031 or W-series No.
(L•n'.dank Ir not known)
Township Name Township No. Range No Section No. Fraction Ism.-1.Ig) Date Sealed Date Well or Boring Constructed
Orono 117 23 07 31-003f 2.0 rt)rC . 02-
Numerical Street Address or Fire Number and City of Well or Boring Location /
1214 Wi l dhu r s t En , Orono 55364 Depth Before Sealing /V`_ h Original Depth ! • 5. ft
Show exact location of well or boring - ' Sketch map of well or boring A�L_O,_UIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property ;y�Single Aquifer ❑ Multiaquifer
lines,roads,and buildings. P
N WELUBORING Measured ❑ Estimated
ylWater Supply Well ❑Monit.Well �j
-T---T---,-----,--- \ _ 1 T J, J❑' /
Env.Bore Hole ❑Other // I h. below ❑ above land surface
W---r---,---- --^--r--E l f t CASING�/ TYPE(S)
^-r---I----I -I--- T <.` J` tV Steel ❑ Plastic ❑Tile ❑Other
I I I I
)Smile` '
--- ---i--- i i- } CASING(S)
fDiameter Depth Set in oversize hole? Annular space initially grouted?
��L�"""" �,J� ? r/�� / 1( Yes Nilo ❑ Yes ❑No ❑ Unknown
at, t mile--tea / r m.from C,J to ��/! ft. ❑
OP shWNea NeilE952-472-6955 in.from to ft. ❑Yes ❑No 0 Yes ❑ No 0 Unknown
Property owner's mailing address if different than well location address indicated above. in.from _ to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
C
Screen from /V/ to 1 ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s),�❑ Debris �❑j Fill ❑No Obstructionn ,!
Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) L.1A" f 2 �,) 4/ ��. 7/,'"
Obstructions removed? [ Yes 0 No Describe
PUMP r Pump
Type j PGA"ff<
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
II 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:
H
{Jo Annular Space Exists
•I r 1` ) ) J'/-- ❑Annular space grouted with tremie pipe
`' ❑Casing Perforation/Removal
in.from to ft. 0 Perforated 0 Removed
in.from to ft. 0 Perforated 0 Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cementu/ =94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material!'-�/'�04l (. "4/� bbM to /9/5-ft. yards 3 bags
from to ft. yards bags
from to ft. yards bags
from to_ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? 0 Yes/�I�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.
Don Stddola Well Drilling Co. ,Inc. 27172
Contractor
�Business Name License or Registration No.
•
•''rtho red':presentative Signature` - Date
LOCAL COPY
H 192828 Name of Person Sealing Well or Boring