HomeMy WebLinkAboutwell info WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �O�O[�O
County Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. J
Minnesota Statutes,Chapter 1031 or W-series No.
� (Leave blank'ii not known)
Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
4rvno 117 23 17 2''3-0032 � —
GPS La[itude degrees minutes seconds � / r
LOCATION: Depth Before Sealing �.�L�� ft. Original Depth ��C�s tt.
Longitude degrees minutes seconds qQU1FER(S) STATIC WATEq LEVEL
Numerical Street Address or Fire Number and City of Weil or Boring Location ingle Aquifer ❑Multiaquifer
1865 Concordia St � Orono 55391 WELUBORING �aMleasured ❑Estimated
T
�Water Supply Well ❑Monit.Well i
Show exact location of weil or boring Sketch map of well or b'ring c, �"
in section grid with"X" location,showing prope � ❑ Env.Bore Hole ❑Other J � ft. �below ❑above land surface
lines,roads,and buildin g�
N `,� -�-�1 CASING TYPE(S)
� � ' ' !
-'i-- --i-- `—� �) '
��„k` teel ❑Plastic ❑Tile ❑Other
W --�- - - -- --i-- E .�� WELLHEAD COMPLETION
, � � � � �_-.�. Outside: ❑Well House Inside: ❑Basement Offset ���
-�-- -�-- ' �— .'.
�^"� ❑PitessAdapter/Unit ❑WeIIPit
--�- -i-- -�-- --�-- I
1 �VVell Pit ❑Buried
S y /�
�r mne---�w '\
i ❑Buried
PROPERTY DOWNER'S NAME/COMPANY NAME CASING(S)
T0� U CQ'n AOQie s Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different ihan well location address indicaled above � �
_��In.ffom� to��ft. ❑Yes �No ❑Yes ❑No ❑ Unknown
7526 Turner Rd
Independence, MN 55328 in.from ,o ft. ❑Yes ❑No ❑Yes ❑No ❑ 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 diflerent than property owner's address indica�ed above Screen from�(�t0 /7�ft. Open Hole from t0 ft.
OBSTRUCTfONS
L�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)� .�/'r/� �T�r:%Y ¢ �'�it jw/���
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO DBSCfib2
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
d C i f t % 0 2 6 TYPe�-T(?G I�L���
emoved ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
QiM1lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
��.
in.from to ft. ❑ Perforated ❑ Removed -
in.from to ft. ❑ Perforated ❑ Removed
Type of peHorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material /L`,�r%�L���.uT from�to�h' 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? ❑ Yes o 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.
z-u�...,aa....:r i...�iiJj
Don Stodols We1lDrilling�,. Inc. 27].]?.
e'''''� Contractor Business Name License or Re istration No.
�������� 2 5 �R�� - 9
_ . -.
GITY U1=ORO�Vp -
A ri d resentative Signat - ' Date
/� ^/�^ Jim #ntonson
LOCAL COPY H L O /1 1�.i O Name of Person Sealing Well or Boring
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