HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Bor�ng � A n
WEIL OR BORING LOCATION I ��y�7 y��
WELL AND BORING SEALING RECORD Sealing No I�"� �, i ��
County_Name Minneso!a Unique Na � � I
Nennepin Mmnesota Statutes.Chapter 1031 or W-senes No.
ILea�e biank il no�known�
. Township Name Township No. Range No. Secfion Na Fracuon(sm.�Ig.) Date Sealed Date Well or Bonng Constiucted �
Orono 118 2 36 4i-9p3 �2 �;� �
Numerical Street Atldress or Fire Number and Ciry of Well or Bonng Location � �
lfld Chevy Chase �L`� �r��� Depth Before Seahng ��� _ft Original Depth ��� n
Show exact Iceation of well or bonng Sketch map of well or nng ppUIFER(S) STATIC WATER LEVEL
- in section gnd wdh"X'. IocaGon, showing pro e, �j Single Aywter ❑ Multiaquder
lines,roads,and buddin s�. �( '
N �. WF,�UBORING 'Ll Measuretl ❑ Estimated ��
' .�.�.��..... ...----..-....� .,3 L�Water Supply Well ❑Monit Well � �I -
- - - - - - t
❑ Ern.Bore Hole ❑Other _ fl. �below ❑above land suAace
W -�- -i-- - -- --i- E ..•, CASING TYPE(S)
' � � � � ._._..._...� `i -
� -�- -�- -�-- --�-- � �-`=���T . ,' Steel ❑Plastic ❑Tile ❑Other
�c mde �'"'y�
� � CASING
-�-- 1-- --�-- � Y�'
,t Diameter /� Depth t� � Set in ove�size hole? Annualar space mi6alty groutetl?
S � �! i✓ � T� Ves No ❑ Unknown
�y.--i m�re—�» _ ,.,.,, �--'E _ ~}'- ' ..s in.trom to tt. ❑ ves �lo ❑ ❑
PROPERTY OWNER'S NAME -�" in.from to fl. ❑ Yes ❑No ❑ Yes ❑Na ❑ Unknown
P�opeM a+'^ei s mailing adtlreu if ditt rent than well location address indicated above. in.from to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
���Ml�i Ryerse 475����U SCREEWOPENHOLE . � f
7 y
1�.�.��� � L,,;,,�.., y_.! • Screen from �L�'-`, to �-'�" ft. Open Hole trom to ft.
- ��� { OBSTRUCTIONS
�.�..3� .y._, �,.>
WELL OWNER S A' �Y �Rods/Drop Pipe ❑Check Valv=(s) ❑ Debris Iy--I„Fill ❑ No Obstryction
Well owners maihng address it diflarent t�an property owner's adtlress indicated above. Type ot Obsl�uctions(DeSCribe) �"`����, " �� � S��•
Obstruclians removed? �Yes ❑ No Describe
PUMP
Type
GEOLOCi1CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed L�Not Present ❑ Other �
If not krawn,indicate estimated tortnatbn log from nearby wORM�Og METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ��
�r��� O �� �No Annular Space Exists
❑Annular space grouted with tremie pipe
� ❑ Casing Perforation/Removal
in.from to ft. ❑ PeAorated ❑ Removed
in.from to fl. ❑ Pertorated ❑ Removed
Type of pertorator
❑ Other
GROUTING MATERIAL(S)
/
Grouting Material ti�`�� r'�/,�'-G�f�m � to /� fl. yards � begs
from to fl. yards bags
from -to � fl. yards beys
from to__ tt. yards Dags
'- REMARKS,SOURCE OF DATA,DIFflCULTIES IN SEALING OTHER W ELLS AND BORINGS
� Other unsealed and unused well or bori�g on property7-0 Yes- ,�Jo How many? - - -- - `
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
;. This well or bonng was sealed in accardance with Minnesola�Aules,Cfiapter 4725.�The inlortnation contained in lhis report ie '�
� true to the best of my know�edge.
� I)on StodolaWell Drill�n� Co:; -Inc. 2?1�72 '
Contractor Business Name License or Regishation fvo.
�-;�f r�� �� ;=�-'`� :�-�r �4-13-9 9
tho ed Representative Signeture _. ,_ Date '
Jim Anion��xt
� _ . ,
H e Name o!Person Seali�Well a Boring
d.O�AL C(3r�Y J
HE-01434-04 8/98 R