HomeMy WebLinkAbout1994 - Well & Boring Sealing Record WELL OR BORING LOCATION Minnesota Well and Boring H 5 502?
MINNESOTA DEPARTMENT OF HEALTH Sealing No.
County NameWELL AND BORING SEALING RECORD Minnesota Unique No.
Hennepin Minnesota Statutes.Chapter 1031 or W-series No. l�
(Leave blank it not known)
Township Name Township No. Range� No. Section No. Fraction(sm. •Ig.) Dale Sealed Approximate Date Well
Orono 117 23 08 4 -00,Q5 Ir4 7.1-(...),,,...1r !� or Boring Constructed
Numerical Street Address or Fire Number and City of Well or Boring Location <� �S/ /
3430 Northshore Drive Ori, Mn. Depth Before Sealing / 0 ft. Original Depth -. /C/� ft.
Show exact location of well or boring Sketch map of well or boring Static Water Level XAccurate
in section grid with'X". - --• lines.
roads.and• ildings. ❑Approximate
N
4/0 i •
i lieSingle Aquifer CI ^Multiaquifer ft. below above land surface
- 1 - CASING TYPE
W ' E L'_
T >teel ❑Plastic ❑Tile 0 Other
I 1 v mile
Screen from -- `•3 ? to 70 /
ft. Open Hole from to B.
1.0.---/mile—►I /vii.I(-i t', l',.a( r • OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME Ig/Obstruction ❑Debris ❑Fill
Water & Asscseiates, Inc. ' _ '`.._
Type of debris/obstruction .I41,1�`r PLP) 9 ✓E
Mailing Address if different than property address indicated above.
10340 Viking Drive Obstruction/Debris/Fill removed? %Yes 0 No
S. 110 PUMP
Eden Prairie, Mn. 55344 U<_i Foley
Removed 0 Not Present 0 Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring.
drift 0 /� i
y 4n I in.from v to /3+L..1 ft. ❑Yes $No ❑Yes CI No ❑Unknown
i V in.from to ft. 0 Yes 0 No ❑Yes ❑No 0 Unknown
in.from to ft. 0 Yes ❑No 0 Yes 0 No 0 Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
Ylo Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to _ ft. ❑Perforated ❑Removed
- - -- Type of perforator
r —..-1
❑Other
GROUTING MATERIAL
/
Grouting material/_W.'" C'0?w/ from to /9/U ft. yards 3 bags
from to ft. yards bags
REMARKS,SOURCE OF DATADIFFICU,LTIt IN$
(OCTC1 y,git
from to ft. _ yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? 0 Yes 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.
DONT S'I'O XLA WELL DRILLING CO., INC. 27172
Contractor Business Name License or Registration No.
i
///�y�/ � -- .74 6x-30-94
uzi ed Representative Signature Date
I.L:CAL COPY H 55022JimAntonsan
Name of Person Sealing Well or Boring
HF_n1n•Id_n1