HomeMy WebLinkAbout1997 Well and Boring Sealing Record v
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 115664
Minnesota AND BORING SEALING RECORD SealingH
County Name Minnessottao Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.- Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 23 33 r4 u 14
11/241/97
Numerical Street Address or Fire Number and City of Well or Boring Location p
51 North Willow Drive Depth Before Sealing 8 5 ft. Original Depth ft.
—
Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property XJ Single Aquifer 0 Multiaquifer
lines,roads,and buildings.
N WELL/BORING )(J Measured ❑ Estimated
0 Water Supply Well El Monit.Well
_-T_—_T____,-_-__l__- C q
❑ Env.Bore Hole ❑Other 5 4 ft. )J below ❑ above land surface
W r —I I E CASING TYPE(S)
I I
---I--`--I -I I NJ Steel El Plastic El Tile 0 Other
I I I I a mire
i_ _-I__ I i___ I CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
S
liJ
(r t mile
4 in.from _ to 81 tt. ❑Yes )0 No El Yes I7]No $ 1 Unknown
PROPERTY OWNER'S NAME I in.from to ft. ❑ Yes El No ❑Yes ❑No 0 Unknown
Mrs Ivan Gunsolus
Property owners mailing address if different than well location address indicated above. in.from to ft. 0 Yes ElNo ❑ Yes 1:]No 0 Unknown
51 North Willow D r. SCREEN/OPENHOLE q
Orono , MN 55323 Screen from 81 to 84 ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME
0 Obstruction 0 Debris 0 Fill J No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill
Obstruction/Debris/Fill removed? 0 Yes 0 No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO til Removed 0 Not Present ElOther
FORMATION
If 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:
QNo Annular Space Exits
0 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)
Grouting Materif4 eat Cern_ from _0 to R 5 ft. yards_l_____ bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? 0 Yes 7 No
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.
Stevens Drilling & Env. Services 136654
Contracfgr Business Name-. License or Registration No.
\ t
----- 11/21/07
Authorized Representative Signature Date
Richard Stevens
LOCAL COPY H 115664 Name of Person Sealing Well or Boring
HE-01434-02
10/958