Laserfiche WebLink
.� <br /> wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � 2�g 5 5 <br /> County Name <br /> WELL AND BORING SEALING REC RD Mennle90 aoUnique No. <br /> I3ennep j.A Minnesota Statutes,Chapter 1031 or W-series No. <br /> T' (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed '��.. Date Well or Boring Constructed <br /> Orono 117 23 Ob 2Lr-OOd2� ` ` � <br /> Numerical Sheet Address or Fire Number and City of Well or Boring Location • <br /> 4'i J 5 �ays ide RD, Or�I�O S 5 3 59 Depth Before Sealing � r-' ft. Original Depth ��i� , R. <br /> Show exact location of well or boring Sketch map of well or boring Ap IFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Single Aquifer ❑ M Itiaqui r <br /> lines,roads,an.d.b dings. <br /> N �; �� � WELUBORING � �Measured ❑ Estimated <br /> _ .'.� - ,'rti�;.,,,,, <br /> � Water Supply Well ❑Monit. ell ,� i <br /> - - - - - -- --;-- 1 <br /> � � � <br /> � <br /> � � � <br /> T T � , - <br /> I I I � `� r ❑ Env.Bore Hole ❑Other � � �' ft. �below ❑ above land surface <br /> � � � � � � <br /> W —�- -i-- -i-- --i-- E � .....�..._,.... CASING TYPE(S) � <br /> --�- -�-- -�-- --�-- �� Steel ❑ Plastic ❑Tile Other <br /> � ;Gmlle � � _.��. � <br /> --�- -�-- -�— --�-- ,_ ...._._. ._.., CASING � <br /> � �_.._ Diamet�r f De th � Set in oversize hole? qnnualar space initially grouted? <br /> pt�i m��e , , � � in.from '�� �L �� R. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.from ry. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address if diflerent than well location address indicated above. in.from fl. ❑Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE � <br /> f, '� <br /> t „�, `�} �'°.��� Screen from �� �/ � to , it. Open Hole from to ft. <br /> 'p i`y,p i.✓ <br /> OBSTRUCTIOWDEBRI ILL <br /> WELL OWNER'S NAME �� � P Obstruction ❑ De ris Fill �No Obstruction <br /> S �.� <br /> Well owner's mailing address if different th�r' ropeAy owners adqr@sai�qjcated above. Type of ObsiructioNDet�ris/Fill <br /> Obstruction/Debns�Fill r Imoved ❑ Yes ❑ No <br /> PUMP <br /> Type_� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed � No Prese ❑ Other <br /> FORMATION <br /> If not known,indicate estimated tortnation log from nearby well or boring. METHOD USED TO SE L ANN LAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . ,� ,') ;.,� � <br /> No Annular Space 6cits <br /> ❑ Annular space grou�with emie pipe <br /> �� ❑ Casing Pertoration/ emova <br /> in.fr m to ft. ❑ PeAorated ❑ Removed <br /> in.fr�m ro R. ❑ PeAoreted ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL�S) <br /> 9 f �c✓:%!. ',!!✓--{f {.� < /' <br /> Groutin Material from to ft. yards �� bags <br /> from to ft. yards bags <br /> � <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> HEMARKS,SOURCE Of DATA,DIFFICULTIES IN SEALING UNSEALED WEL�S AND BOR NGS <br /> Other unsealed well or boring o property? ❑ Yes ,�No <br /> LICENSED OR REGISTERED ONTRACTOR CERTIFICATION <br /> This well or boring was sealed i accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best at my knowledg . <br /> Don �tadol 6�ell Driilin co. Ine. 27I22 <br /> Contractor Business Name - License or RegisheHon No. <br /> .....,..� . , .- <br /> - � , �, <br /> ..�_r ,.; v; �, �. <br /> Autho ed epresentaNve Sig fure Date <br /> e- <br /> \'� r w ,,,,...a� ,� t`./.tJl�V��.. <br /> LOCALCOPY <br /> H 12 7 9 5 5 Name ol PersoA Sealing Well Bonng <br /> HE-01434-02 "� <br /> 10/95R <br />