HomeMy WebLinkAbout1996-08-22 Well and Boring Sealing RecordWELL 011 @011111G LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 107 13Seating
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County Name WELL AND BORING SEALING RECORD M nnesotaoUnique No.
Hennepin Minnesota Statutes, Chapter 1031 or W-senes No.
(leave N.* it nit k--)
Township Noma Township No. Range No. Section No. Fraction Ism. -w Ig.) Date Sealed Date Well or Boring Coinstnrcted
Orono 117 23 4 8/22/96
Numerical Street Address or Fire Number and City of Well or Boring Location
60 Cygnet Place Depth Before Seating 1� It. Original Depth 1,1,E h
Show exam location of well or boring Sketch map of well or boring AOUWEIyS) STATIC WATER LEVEL
in section grid with'X'. /,'� location, showing Property e A urfer
Imes. roads, and buildings �i^91 q ❑ Muffiaginfer
N WELLIBORING Z Ide.iswed Esi-aled
-T- -+- -*- -i-- Cfaler Supply Well ❑ Mont Well
❑ Env Bore Hole ❑ Other _ it belox C above land surface
W "+' -'�'- 't I E _ CASING TYPE(S)
4- -?'- 4- []Seel ❑ Plastic ❑ Tile ❑ Other
4 mxa
-i I CASING
l � 1 Diameter Depth Set in oversize hotel Annualar space initially
itialty grouted?
aft-- fins.--�Ir _,4 in Irom _0._ to — It ❑ Ye5 No �' Yes ❑ NO El Unknown
PROPERTY OWNER'S NAME In from -_ to __ It ❑ yes ❑ No ❑ yes ❑ No ❑ Unknown
Dan Currier
Property owner s mal, g ad9niss d a flerent than won location address indC led above ) Irom _ _ to _ h ❑ Yes ❑ No ❑ Yes ❑ No []Unknown
SCREENIOPEN HOLE 1
Screen lion,_�-._ to _.1,..a3_ ft Open Hole from to _ tt
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME LAObstructnon ❑ Debris ❑ Fill ❑ No Obstruction
Wee ow+*es mNkg address it different than property owner's address indicated above Type of Obstruction Debns/Fdl Pump S—Yi e —
ObstnutiOrVDebnsfFill removed? [ki Yes ❑ No
PUMP
rT-yype Su. aelrgj�ble
GEOLOGICAL MATERIA'. COLOR ��ASS N FROM TO YC'emoved ❑ Not Present ❑ Other
If not known. indicate estimated formation fog from nearby wee or boring METHOD USED 10 SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
drift 11 EkNo Annular Space Exits
❑ Annular space grouted with trem-e pipe
❑ Casing PerloratrontRemoval
in from to _ It ❑ Perforated ❑ Removed
in from to _ ft [I Perforated ❑ Removed
Type o! perforator
❑ Other
GROUTING MATERIAL(S)
---- Grouting Matenal 'pQ'., bland - from _ 11310 _$ It _ yards —19 bags
from to If yards bags
from to ff yards bags
from to ft. yards bags
IREMAINKS, SOURCE OF DATA, DIFFICULTIES IN SEALING UNSEALED WELLS AND DOP44GS
Other unsealed well or boring on property? ❑ Yes
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules. Chapter 4725. The udm oratgn contained in this report is
true to the best of my knowledge.
SAP R-W.S.- Nall Ori21+r,] 27276
Contractor Business Name License or Registration No.
4r
AuMonred Fleoresen!- aaT ^Sprafura Date
LOCAL COPY FH-11 0 713 8 "° ' 4M.,
HE-01�74-02 lflw