HomeMy WebLinkAbout Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H205704
WELL AND BORING SEALING RECORD Minnlesotta Unique Well No.
County Name —
Hennpein Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank II not known)
Township Name Township No. Range No. Section No. Fraction Ism-)-.Ig) Date Sealed Date Well or Boring Constructed
Orono 117 23 20 314-0001
GPS Latitude degrees minutes seconds n
LOCATION: Depth Before Sealing ft. Original Depth–
Longitude
epth Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ❑Single Aquifer ❑Multiaquifer
3035 Casco Pt Rd, Orono 55391 WELUBORINGeasured E]Estimated
iNater Supply Well E]Mont.Well /
Show exact location of well or boring ring
in section grid with"X" location,showing prop rty E] Env.Bore Hole C]Other ft. below ❑above land surface
N lines,roads,and buildi gs. CASING TYPE(S)
Steel ❑Plastic ❑Tile ❑Other
W --�- - -- - -- -- -- E WELLHEAD COMPLETION
�{ Outside: ❑Well House Inside: ❑Basement Offset
Yemib ❑PitessAdapter/Unit IZwell Pit
4-
1 D 1 P ❑Well Pit E]Buried
I\A ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
95?-471-7204 Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above I' y�
in.from (111) t0 ft. ❑Yes �lo ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREENIOPEN HOLE
Well owner's mailing address if different than property owner's address indicated above Screen from ZZ-R to_W.!7 t. Open Hole from t0 ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) ��j,( 4+- �A/M®
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?FORMATION es El No Describe
If not known,indicate estimated formation log from nearby well or boring PUMP
Type
/
❑ Removed of 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 MATERIIIA/L(S)D/} (One bag of ccement== /
94 Ibs.,once bag of bentonite=50 lbs.)
Grouting Material r,t/'�(y 7 C"!2 1f•/�}Z eO to 11.2 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 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.
Contractor Business me License or Registrati�oryn c
Afrher—eserii5rva Signatdre. �t[ , Date
LOCAL COPY H q n;I n di ' �•. �
Name of Person Sealing W0 or Boring