HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 5 4 9 5 4
County Name
WELL AND BORING SEALING RECORD Minnle9oNa Unique Well No.
Hennepin Minnesota Statutes, Chapter 1031 or W-series No.
(Leave blank i�not knownJ
Township Name Township No. Range No. Section No. Fraction(sm.-+IgJ Date Sealed Date Well or Boring Constructed �
Orono 117 3 2 24 YO '� '� �v(��/' OC�
�} .
GPS Latitude degrees minutes seconds Depth Before Sealing 7� ft. Original Depth ft.
LOCATION: Longitude_._ degrees__._ minutes__ _ seconds
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ���Mf AQ�J
3/�p +� Measured Estimated Date Measured ��� �i�'
C1C�� �C� Point Rd, �r� 55,7'1 Y✓ELUBORING / ❑ ---
, I Water-Supply Well �i Monit.Well
Show exact location of well or boring Sketch map of well or boring -
in section grid with"X" /"�'• locati showing pro rt I_i Env.Bore Hole ❑Other �� h. �below ❑above land surface
� 'ine ,�d�,an3buil�
N � „�Y �s�h. J�. CASING TYPE(S)
----------- --- ----- -- . _____ . ���Steel ❑Piastic ❑Tile ❑Other
� WELLHEAD COMPLETION
W E �\
° � � � � � Outside: !]Well House i_i/+t Grade Inside: ❑Basement Offset
, --�--- ---�----�-- ---�-
iie ��Pitless Adapter/Unit ❑Buried ❑Well Pit
' --�--- --�-----�- ---�- ��.
- ❑Buried
�Well Pit
S ❑Other
�t Mile� []OthOf
�OPERT�OWNER'S NAM COMPA �Ej CASING(S)
� 7NtZ�r�t� ��� '*����2 Diameter r Dep � Set in oversire hole? Annular space initially grouted? �
Property owner's mailing address if different than well location address indicatetl above �� /_ �,(
- �in.fromi� to �� ft. ❑Yes �/]Wo ❑Yes ❑No ❑Unknown
5
{ in.from to ft. ❑Yes ❑No ❑Yes �]No �L]Unknown
� - in.from to ft. Yes
[] ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME � SCREEN/OPEN HOLE / �
r (
Well owner's mailing address if different ihan property owrer's address indicated above SCfeen(rom�, to�J ft. Open Hole from to ft.
OBSTRUCTIONS
' Rods/Drop Pipe ❑Check Valve(s) �',Debris ;�Fill ❑No Obstruction ��
Type of Obstructions(Describe)���C.r'J �G'J 3 � �"������/\J
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7�I Yes ❑No Describe
FORMATION --
PUMP
If not nown,indicate estimated formation log from nearby well or boring. �rn�,v� /�u��
Type J���� /�
`-�"' ��J (�Removed ❑Not Present [J Other ___
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�� No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perioration/Removal
in.from _..__._to___ ft. ❑Perforated ❑Removed
in.from to ft. LJ Perforated [',Removed
Type of Perforator _
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�` A� r ��'' •
GroutingMateriaV"��� C=/�r'�- from � to Z ft. yards� bags
from to ft. _ yards bags
from___ to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �I Yes�No How many?
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.
Dan Stodola Well Dcil n C ' . _15�1_
Contractor Busines a /' License or Registration No.
3 � r' _ / / // //_
1. / �+� �J 'GJ
��.
C ied presentative Signature ,, Certilied Rep.No. Date
= F., 5 4 � �. �'..:�-� .�,,�..,�� �,
LOCAL COPY 2 9�4 —�
Name of Person Sealing Well or Boring
HE-01434-09 IC#140-0423 �� �� s/oea