HomeMy WebLinkAbout1997-08-04 Well Sealing RecordWELL OR BOOM LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bc
WELL AND BORING SEALING RECORD Seating �r 126521
County NameWELL Unique No.
Hennepin Minnesota Statutes, Chapter 1031 or W-senes No
I�N�e Marl a rqr ono+*, L—
Township Name Town" No Range No Section No Fraction ism i Ig I Date Sealed Date Well or Boring Constructed
Orono 11 2 02 1 4r3-002 r-
Numerical Street Address or Fire Number and City of Well or Boring Location
1045 H Ferndale rd, Orono Depth Before Sealingh original Depth 2co it.
Stow exact location of wall or boring Sketch map of well or boring A ER(S) STATIC WATER LEVEL
in section gnd with -X- ia.ahon show'ng property mgie Agwtrn j 4lulfcfquAer
N ' 1 i,nec roads, antl bu�IdNgs
WE ORING X—swed El Estimated
Water Supply Well ❑ Mond Wcll f
(-] Env Bore Role ❑ Other _-- -- -- _ G If ;Weow ❑ above land surface
W - %•- •?- •i-• E _-_ �... CASINGTYPEIS)
"E- •i-• -�-- -�-- ( ' Steel ❑ Plastic ❑ Tile ❑Other
r � I
LmM
PROPERTY OWNERS NAME
VfeQariy ewnais mailing address d afferent than wail lo(alion address . o—ted above
1055 14 Ferndale Rd
Orono, 11N 55391 476-1720
WELL OWNER'S NAME
WON owns mtlrq address it dlffwent than property owners addrau ,nO,caled above
OEOLOW,AL MAMMAL I COLOR SSOI FORMATION I FROM I TO
rot krom , xtdtala aaMriand lomiaaon leg hom nearby was or boring
CASING
Diameter Dept
Set in oversize hale'
Annualar space initially groutedl
in Irom to �� It
❑ Yes XlNo
❑ Yes ❑ No ❑ Unknown
in fr— to h
❑ Yes ❑ No
❑ Yes ❑ No ❑ Unknown
in from to h
❑ Yes ❑ No
[J Yes ❑ No ❑ Unknown
SCREENlOPEN HOLE
% 6' cat
Screen from to h Open Foie
from to
if
OMTRUCTONDEORMLFILL
Obstruction ❑ Debits ❑ Fill ❑ No Obstruction
Type of Obstruction-DetxlLFlll 1 1A-'
1:24IM P
ODstruclaNDebrlaFdl removed? Ky. ❑ No
PUW
Type -
WRemoved ❑ Not Presets ❑ Other
METHOD USED TO SEAL ANNULAR SPACE METWEEN 2 CASINGS, OR CASMW AND 1011E NOLE
No Annual Space Exits
- ❑ Annular space grouted with frame pope
J ❑ Casing PertorahoniRanoval
in from to h ❑ Pentoralsd ❑ R.niovad
n from to h ❑ Parbnated ❑ Rentotr.d
Type of perforator
❑ Other
Grouting MaterialIf
Yard.
Iron, _ to h Yards baps
from to it _ Yards bap
from to _- _ it Yards bap
PONAMPAk SOLV CE OF DATA, DMRCULTIES IN t[AUIIO UNSEALED WELLS AND POMIGS
Other unsealed well or boring on property? ❑ Yes X.
LICENSED OR REGWTEREO CONTRACTOR CERTIFICATION +
This well or boring was sealed in accordance with kknresols Rubs. CMpNr 4725 The oft ntoft Contained in it" rspot la
true to the best of my knowledge
Don Stodola Well Drilling co., Inc. 27172
Contractor Business Isms License a, RepWr~ No.
A.mon•od Representative sWisture EE; DaY
LOCAL COPY
TH 126521 Name of Pbrsai Sealing, ~ or Bong
NE-0114"
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