HomeMy WebLinkAboutWell info wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring H 112 9 � 3
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
q (Leave blank if not known)
Township ame Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date�Vell or Boring Constructed
Orono lI7 23 08 ' ' U(/ Co
Numerical Street Address or Fire Number and City of Well or Boring Location �
1!.�/_ n�1.1... t1�.,� n� Depth Before Sealing �.�L.�` ft. Original Depth �d ft.
'YY°i �Li1441 r�A Att
Show exact location of well or boring Sketch map of well or boring AqUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, wing property Sin le A uifer
lines ds, d buildings. 9 4 ❑ Multiaquifer
N WELUBORING �easured ❑ Estimated
� � � Water Supply Well ❑Monit.Well �
---- -i-- -;-- --;-- t ,�`
� �
�� ��\ ���� ❑ Env.Bore Hole ❑Other �ft. �below ❑ above land surface
� � � �
� � � ` \
� ,.
W --i- -�-- --i-- --i-- E �� �� �� �CASING TVPE(S) ,
� � `.-
i � � Y ,
--�- -i-- --�-- --�-- '-� Steel ❑ Plastic ❑Tile ❑Other
u mile ,�(,f
__L_ _J__ __J__ __�__ � �"r CASING
,.N
Diameter Depth r Set in oversize hole? Annualar space initially grouted?
l� � ""�J�� ��� �� � �
q{�-1 mile�s ;� m.from to ft. ❑ Yes '[�lo ❑Yes ❑No ❑ Unknown
I I
PROPERTY OWNER'S NAME _ in.from ta ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
Property owner's mailing address if diHerent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
i /�,/'�1
Screen from�to `4'L fl. Open Hole from to ft.
O B ST R U CTI O N/D E B R I S/FI L L
WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill �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? ❑ Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BEIWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� ' `�No Annular Space Exits
,:
. ❑ Annular space grouted with tremie pipe
r
�' ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in,from to n, ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUT�NG MATERIAL(S)
�� t
Grouting Material r 06m �_ to� ft. yards �_ 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? ❑ Yes o
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.
zx� sL�ia �a.�. �x�.u� co., ��. 27I72
Contractor Business Name / _ License or Registration No.
.�,,.-' /_: J !- _7�
f J
ori��p _ arve Signatuie '..- "" Date
, i � :
� ��t_ ;.;� A_ �.�t��__./"t.��:`�..1�.�r;-�:� :
r � Name of Person Sealing W�or Boring
LOCAL COPY H � � �` � � � �
HE-01434-02 k
10/95R E
STATE OF MINNESOTA MZN9ESOTA UNZ@UE WELL N0.
�PaRTr£rrroFH�n� WATER WELL RECORD 127355 I
for W¢ter Srmrple
l. LOCATION OF l7ELL Minnesota St¢tutes L56A.OL-.OH
_"'_____�_—__
� Co�mty Name Fraction Section Number Tovnship N�her Renge H�ber 3. �OPERTY ONNER'S NAFff - '--�-� '
� � � � ����� .... �.
N. or 5. E. or N. Address � t� �"`��
Distence and Mrection f?om Road Intexsections or Streec Address and City of We11 Locacion � ��as�,q. �� �Q:i.
��� �i
........__.'_-"'...._.._._...__......__...,__..__......_._
Shov exact location of vell in section grld with 'X.' Sketch map of well location. , }/gLL DEP77[ completed) Date of Completion
N
- L -,- ! �- � n. a�.'•�a��
W _ ± �- y E 5 1Q Cable Lool 4❑Reverse 7❑Driven LOQ Dug
+-
' i , '�Hollw rod 5❑Air �Bored ll�
, �� � ' , '�mi. 7�Rotary b❑Jetted 9�Power Auger
-� � :�.'___
� ___ ... -'---- - -� -- 6. use
+ I� __.
S 1�Domestic �Public Supply 7U Industry
~—1^^�� Z❑Irrigation �Air Conditioning 8❑Covvnercisl
HARDNE55 OF
2. FORMATION IAG COLOR FORMATION �OM TO 3❑Test Nell 6❑
�� � �� � � 7. CASING HEIGHT: Above
DIAM.
Threaded�1 Welded Q 3I Surface ft.
Slack �� Gelv. �4I
� & � � �in. to � ft, depth ( Weight �*E**►"�' lbs./ft.
in. to ft. depth I
in. to ft. depth Drive Shoe? Yea No
. SCAEEN Or open hole
Meke ��wey�i from ft. to ft.
�� '4'Pe S r-i�-..13lJ��Dia. ��
t� Slot/Gauz---y;e�� Length � .
�j�� FITTINGS:
Set betveen�F61 fc. and� [c.
f[. and Et.
_ f[. and f[.
�
9. STATIC WATF.R LEVEL
� � ft.�lov �above Date Meesured���l.� (.
� land surface
10. PUN�+'�IttG.LEVEL belw land surface
�"'� ft. aTter � hrs. pumping � g.P.m.
ft. after hrs. pumping g.p.m.
11. WELL HF.AD COt�LETIOH
i�Pitleas adapter Z❑Sasement offset �❑At least 12" above
qrade
12. 'dell gmuted?
� �Yes �No Cu. Yds.
1❑Neat cement 2❑Bentonite 3�� ��_. �� "
�� Denth: from ft. Lo ft.
Ifrom ft. to ft.
li 13. Nearest source of possible contaminatian �
��� _feet di recti on type
._ Well disinfected upon completion? Yes� No�
1 . PUN�
Date inetelled �����
�Not installed
_ Menufacturer's Neme � ��
hbdel t7umDer kIP �7 �� Volts f,�._
Length of drop pipe �i{yF ft, capaclty�.� g.p.m.
Materisl of drop pipe �# ���♦
Type: 1�Submersible 3O L.S. 'Purbine SQ Reciproca[ing
Z❑Jet 4❑Centrifugal 6�
16. WATER WELL CONTRACfOR'S CERTIFICATION
This vell was drilled under qv ,Jurisdiction and this report is Lrue to
the best of vd knwledge and belief.
�ae a aecond aheet i needed. � � �'�� �'t�� �a �„��
15• ��K�, ELEVATION, SOORCc OF DATA, etc. Licensee Busin¢sa Name Lticense No.
Address_IE��+'_�. � � ���� � !�F-_����
_> -,� .,y„>. - ,,
Sip3�e .���'":.:...�� t'�:'Y+�r.x'�"'"����Date -
Authorized Repre�entative
` LOCAL COPY �� �� �
Neme of Driller 7/74 30M