HomeMy WebLinkAboutWell/Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2611701
SealWELL OR BORING LOCATION WELL AND BORING SEALING RECORD Minnesota Well No.
County Name 'I
Minnesota Statutes,Chapter 1031 or W-series No.
v ne n i+ (Leave dank R-1,10.1))
Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 3 29 '' '/ -2-3 J ukt' 07
GPS Latitude degrees minutes seconds Depth Before Sealing 7 ft. Original Depth ft.
LOCATION: Longitude_____. degrees minutes secondsUIFER(S) STATIC WATER LEVEL
A
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
3800 Wayzata
Blvd {, � W LL/BORING Measured ❑Estimated Date Measured
�OIJI! �vti@ D i� Water-Supply Well ❑Monit.Well r
Show exact location of well or boring Sketch map of well or b g n
in section grid with"X.' location,showing p erty ❑Env.Bore Hole ❑Other / ft. below ❑above land surface
N lines,roads,an ildgs\t CASINGTYPE(S)
in
Steel ❑Plastic ❑Tile. ❑Other
-- --------------
WELLHEAD COMPLETION
, T
W E I y,�
--I-___- _ _ ----_ Outside: ❑Well House At Grade Inside: ❑Basement Offset
%Mile pitless Adapter/Unit Buried ❑Well Pit
T ❑Buried
,pSyJp,. 1/�^ ❑Well Pit ❑Other
�L _YD &A 166+40 MILT ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME Li CASING(S)
M Wi Diameter f DepthIF Set in oversize hole? Annular space initially grouted?
in.from ♦
Property owner's mailing address if different than well location address indicated above �� �� to / ft. ❑Yes No ❑Yes ❑No ❑Unknown
Carl Bolander & Sons Company in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
251 Starkey St
.St Paul 3, M 107 _in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if different than property owners address indicated above Screen from !3 to Open Hole from to ft.
OBSTRUCTIONS
Rods/Drop Pipe [j Check Valve(s) ❑Debris E]Fill E]No
Obstruction
Type of Obstructions(Describe)_7-�//� /'/ %L
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe
FORMATION — - ----
PUMP
If not known,indicate estimated formation log from nearby well or boring.
Type
Removed ❑Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑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 Ibs.,one bag of bentonite=50 lbs.)
Grouting Materia/rvEg/ 0417!�Ur from to/I ft. yards-je-,2_ 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 Alo 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.
Dan Stc&l a W11_ nf'i���j�-CDs a 1ac a �f�r
Contractor Business Name 1 tcense or Registration No.
ti epresentative Slghature Certified Rep.No. Date
LOCAL COPY H 261701
Name of Person Sealing Well or Boring
HE-01434-09 IC#140-0423 6/068