HomeMy WebLinkAboutwelll info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � 13971 Q� .
WELL AND BORING SEALING RECORD Sea�ing No H
County Name Minnesota Unique No. -- —1
Hennepin Minnesota Statutes,Chaprer�03� or W-series Na �__ �
ILeave blank if not known�
Township Name Township No. Range No. Seclion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Gonstructed
arono lI7 23 08 3 ,�!0017 �..
Numerical Street Address or Fire Number and Ciry of Well or Boring�ocation
1470 Cherrp Place, �r�n� Depth Before Sealing 2�__ fl Original Depth �l�h
Show ezact location of well or boring Sketch map o(well r�ooring ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing�roperty Single Aqwfer ❑ Multiaquifer
lines,roads,and bGildings.
N 1 WEWBORING Measured ❑ Estimated
.,_.._ Water Supply Well ❑Monit.Well /
- - - - - -- --;— j� _+ � /�
{ ` ❑ Env.Bore Hole ❑Other _ _..�C�/_R. �below ❑ above land surface
� � � � ,
� � � � �, �
W --r- -�-- -�-- --�— E � �� � CASING TYPE(S)
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i i i �
i i i 1� `, '
-�-- -�— --;-- --�-- �1`` ���, Steel ❑ Plastic ❑Tile ❑Other
u mde �
--`- -�-- —�-- --1-- �.,. � CASING
�;, Diameter t� Depih / Set in oversize hole? Annualar space initially grouted?
S """��J""" . ...,_._...,_..... j
�t miie—�s � in.from� to� R. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown
I
PROPERTV OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
Ra G e -
Pioperty owner's mailing address if different ihan well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
i ^�/�/ '
Scieen rrom�_toGi.� ft. Open Hole from ro fl.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Dro Pi e ❑Check Valve s ❑ Debris
� p p O ❑ Fill No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type ot ObstruCtions(DesCribe)
Obstructions removed? ❑Yes ❑ No Describe
PUMP
TYPe�/i�.[JI� /'"!) �—
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or ponng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� No Annular Space Ezits
❑ Annular space grouted with tremie pipe
J��� ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
F
in.from to fl. ❑ PeAorated ❑ Removed
Type of perforetor
❑ Other
GROUTING MATERIAL(S)
� /j 1
Grouting Materi��� �j ��f i/�-�, from S._,� to,�}__ ft. yards �— bags
from to ft. yards bags
from to ft. yards bags
irom to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATIO
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.
Don Stodols Well Drilling Co., INc. 27172
Contracror Business Name � �.- License or Registration ivo.
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t z qepresentative Signature Dafe
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p.s:i-�. .�.�
LOCALCOPY H
13 9 714 Name ol Person Sealing Well or Bonng
HE-01434-03 2/97 R
JHN-15-2��9 11 : i2 AI•i LcUTHNER viELL INC 952 443 2�82 P. 01
WELI OR f30RINCi I.00ATIpN ����Ee�p�=�'•'•%,r�AI�IVT OF HEA47N Minn��ote Well end Eiorinp � '"�"
L ��ALING RECORD Sselinp No.
ca i �uam� �ND BO���i���::�.� M���aao�au��q�aw����Nc,
Minneeofa�t�rutaa, Chepfar f03! or W-e�rlea No,
..+� (Lnti D4 Y na Ne.n�
1' hip Nema Tbv�i�enlp Na R�nO�No, 6sod o. o�ln�lp,)I Dato 3ealetl /' � �ero W■II or BorM�onetrueted �
a w► I� .�8��0 '' �'U
aP$ Latltudu tlepreee_ minuteo_ eecende pa�W g��gN„np_,�_,It. Or�pin.�D�pih_„ T�h•
LOCATION: Lonqnuds+_ deqrese_._ m�nutu_� eeconde �ijWPl�(6) OTATIC WA1�R IEVCL
Numerlc�l 8truai Addreea or i�ire Oor:nd Clry ol Well o Loo4tlon L���^dU Aqultir ❑Multlaquller
(, � , � 1i+.�LLl�ORING L�Meaaured ❑Enlrtakd Dete Meaeured. _,_
(�W�iar-9upply Well ❑MoHit.W�II
Show ex�ot loo�tian o}well or borinp k;�toh m�p ol well or borinp �m.eoN Hol� (�,Other !� n.
In eactlon prld wlth^ff" locatlon,ehowlng prop•rty ,�1 _ ❑bNow [.]above land eurlene
N Ilnep,ioetl�,�ntl bulldinQe, cAf4INp TypC(8)
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' tS�b�s�� ❑PIut10 ❑TIIB L�Ot�e�
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W I I I f� E � WELLH6AD COY�LlTION �,
--�---•••I-•--•i•• -•-I•• TMu� (�j'� I Oue�lda: ❑WNI Now� ❑Ai draee In�ld�: L�t�aoemen1011ea� '' '
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; � �'tp / � �Pluee�AdeptarNnit ���urba ❑W�II Plt �
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�•• •••I•• ❑Burl�d I
; ; � �' Gl w.0 Pi�
p omer �I
�1 MUa—�• ���OM01 � ""�
/, 4� I
PFID � OWNEp'8 NR MR4NV NRME CAOIWC!(o) '
• Dla ar De h 8ei in overelze hole7 Anrwl�r ap�w Inftlally prouted4
Prop+ny �m Inp Yd �fl d11N WeII loonllon addn�a InC �t�tl,qDqw., ,�In�lrom_� �� R ' ��01�;I�""��
,,;.�.�<<�i cT t� �' ,�fL� �� . ❑Yo. n No r��� ' Ca N� , r�.���� ;I
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u' � In.from w I� rJ Yve ❑No rl ris ❑No (]Unknown
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�'` . !7�l� jl y 7 In,from io e. Q w� I_,J No
❑YeB []No [�Unknown
WELL . '8 NAME/COM1�pAIdY NAME iCRGGN/OPEN NO�C
8cre�n irom /� 6 to 13 r IL 0 m Hole from 10 _p �
WeA ownerl4.r�aAlnp sddrea.l!dlMsrcni ihan D�opvrry ownelx add�eee indkeletl ebov■ p
�i
��arrtuc�rionre
, CJ Rode/orop Plpe U Ch�ak Valv�►�) [�Dobrle ❑FIII ❑No OWI�uaUon ,
'f�pe oi Obaauctlons(Oeso�iha)
OLOLO�ICAL�d4TGpIA{, COLOp HMIDNO/OFi 'AOM TO ❑1`+1 ❑IVo G�wr�o I
�oBG�71oN Obetructlone remawtl7
II not kno�wn,Inelaete eeumet�d fo�m��lon Wp from no wall or borin , p���� _ -- �j�
TYP� "�V— ,�—
(,��mowd ❑Noi Preaent ❑OIN��
i -- _...-
� MlTFlBp USeD TO BEAL ANNULAR YW►C�YITW![N 2 CI►OIN00,OR CA8W0 AND YORi N04�:
❑Nc annular 8pao�E�I�to ❑Annular 8pece Oroutetl wlth Thnml9 Plpv ❑Caelnp Perloraslon�Removrl
� In.Irom b _h.
. ❑P�Ao►�ted (;;7 Removed
_ In.Irom to I� (_�Perta�tad �Remaved
lype ol PeAorotor
U Omar
� ' o11DUTiNO MATLIIIAI(8� (On�a�rtrra■0�IO�.,ono b�p cl b�ntonllo a 60 Ie�.)
/ : � �. �.��i
aroutlnp MeNrl+l� Irom��_____r ►e� It, yarde E�ge
i:
trom---- lo It�. Y�rda bape
Iran to N.____,__,,,,, y�rdt bepa
OTMiR YY�LLB I►NO 60WINQB
pCil�A,RKB,eOURC!0�DATA,DI�riCULTIE9IN 9@AL�NO othor una�al�d�nd unuuad well or borinp on properry7 ❑Ytq �'No How meny7____.
L�ClNBCD OR REGIiT6NiD CDNTRAGTOR CRIITIFlCATION
, ,' ThIB W011 0�DO�I�Q Wu Nqlid In aaoord�naa wlth Minneeote Rulea,Chapter 4726,Th�Inlorm�tlon oontelned In th�e repoit
I�trW to l�beot of m nowledge.
�`` � l,v,�,Q ���� �Q�' �,
wo Buelneee Name Llolna�or Replerredan No,
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�� �� ��,����
rt/ed R�prNMfaNw 6lpnelure C'illfkd Avp Ma Daro �•�^�
LOCALCOPY M 1 �r��, l ��'^ �-�
��io,�� Neme al Peroon 5�all�p Woll a Bariny _.__ ,��,,......_�
HE•01434•10 ICa 14o-od23
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