HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � r
County Name WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. ��� ���
Minnesota Statutes,Cha ter 103[ or W-series No.
P aaa�e oia�x i�o�k�ow�,
Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Oraw 117 23 €Ni SW SW N�i -�, b
,
GPS Latitude degrees minutes seconds Depth Before Sealing ,/� ft. Original Depth fl.
LOCATION: Longitude degrees minutes seconds
,f1qUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �YSingle Aquifer ]Multiaquifer /�,/► l
261 Cy�et Place,Orono 55356 N1ELL/BORING �Measured ❑Estimated DateMeasured`SA�+� !}/'+I�
Water-Supply Well ❑Monit.Well f
Show exact location of well or boring Sketch map of well or boring Q,l�
in section grid with"X." location,showing property �_�Env.Bore Hole ❑Other �ft. �below ❑above land surface
N lines,roads,��d buildings. CASING TYPE(S)
--'-----'------`-- ---'-- �"Z��ta
�Steel '�,]Plastic J Tile �I Other _
--�-----�------�-- ---`-- WELLHEAD COMPLETION
W ; ; : ; ET
.; � � � � Outside: �Well House �_1 A�Grade Inside: �Basement Offset _
'h nniie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit
--�-----T----�-- ---%- �
-' ❑Well Pit ❑Buried
S
�-1 Mile� � ❑Other ❑Other
f� s...�.
1�,._l� �Y�.
PR(�f�tT�Y CuQ(N�'�S NAME/COMPANY NANf� (; CASING(S)
rStL aJ8 4�
Diameter � Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if diKerent than well location address indicated above �� / �
� in.from �.O to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown
in.from b ft. ❑Yes �;No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No [;Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE�
/�Ji f
Well owner's mailing address if different than property owner's address indicated above SCreen from1��o�ft. Open Hole from to ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)�L�V/�J+�/? /"sYL s' �/�_/
GEOLOGICAL MATERIAL COLOR HAflDNESS OR FROM TO Obstructions remaved? Yes !]No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. ` /�
Type J�! PUl�1r-�
C�� ..� D I r��" � ---- -
Removed ❑Nat Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from __to fl. ❑Perforated ❑Removed
Type of Perforator
❑Other_
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
. �
Grouting Material/V�p� C�/O�F/�.)I from__S,rL to I� ft. yards_� bags
from to fl. yards bags
__ from to ft. yards bags
OTHEfl WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �-;�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.
Uon Stodole WeII Arillin�; co,. Tnc. 1591
Licensee Business Name License or Registration No.
'" �f - �' i ,�
i resen a e Si n/re Certi�ied Rep.No. Date
�oCAL COPY H 2 914 0 9 �- -.�� ���.�,�-�,
Name ol Person Sealing Well or Boring
HE-01434-12 IC#140-0423 '�,,� 9iosR