HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 0 9 6 4 5
County Name
WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
��enne in (Lsave blank it not known)
Township Name Township No. Range No. Section No. Fradion(sm.�Ig.) Date Sealed Date Well or Boring Constructed
° Orono 1�7 23 �7 S�9 �; S'� 10 ,� �
.
GPS Latitude degrees minutes__ seconds Depth Before Sealing � ft. Originaf Depth ft.
LOCATION: Longitude degrees minutes____ seconds
11QUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Mu,iaquifer �/ nf',/
W LBORING J�I Measured [�Estimated Date Measureds�(�'n/
12�5 ,�'.��'iT4i�C)()(� AV�� ��'� �Water-Su I Well �
pp y ❑ onit.Well
Show exact location of well or boring Sketch map of well or boring �.
in section grid with"X" location,showing property - � ;Env.Bore Hole ❑ ther �� fl. �below ❑above land surface
lines,roads,and buildings. '
N � CASING TYPE(S)
--'-----i-- --'-----'-- �, �
�i �/1$teel �.�Plastic [] ile ❑Other _ _
,' � {��^^''''(( A,
'� '-- --- ---` `-- ..._._,_I� :��. WELLHEAD COMPLETIO
' W � � � E ,.
, T �
�: � � � � ;,Outside: �_.J Well House ❑At Grade Inside: �Basement Offset
- - 1
'h iie ���� � ❑Pitless Adap dUnit ❑Buried �Well Pit
1 C ❑Well Pit L�Buried
' ' S ' - � ❑ome� _
�----1 Mile� ❑�IhOf___ _
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Jftson �l�[ Di et�r ' Depth � Set in oversi e hole? Annular space initially grouted?
Property owner's mailing address if different than well loca�ion address indicated above �?��� .� !]UnknoWn
�, in.from �._._ to_G�C _ft. ❑Yes �No ❑Yes f No ,
8�53 E Aloan3.nt;tan Free�ray _ J
in.from to ft. ❑Yes ;]No i. I Yes I 1 No ! �Unknown
�C� ��
Blaomington, ��'T 55G20 in.from to ft. ❑Yes ❑No �]Yes []No �]Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
e/,.�1,(�+ �
Well owner's mailing address it ditterent than properry owner's address indicated above Scfeen ffom '�-`��to �O ft. Open Hole from to _ft.
OBSTRUCTIONS �'.
�Rods/Drop Pipe ;�Check Valve(s) ❑Debris [;Fill []No Obstruction
Type of Obstructions(Desc ibe) l/1/�� /'l F�' 4- ;,T�/ _
GEOLOGICAL MATERIAL COLOR HARDNESS oR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log trom nearby well or boring.
�,... ' � r�� TYPe
i, ,i_�
� �Remaved � ot Present ❑Other
METHOD USED TO SEAL NNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
I�No Annular Space Exist �_'Annular Space Grouted with Tremie Pipe [�Casing Perforation/Removal
` ._ .___in.fro to ft. [l�.Perforated ❑Removed �
in.fro to _ft. �,',Perforated �i Removed
Type of Perforator
[�Other---_,--
GROUTING MATERIAL(S) � (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
� �`', i . e7 �
Grouting Material�'�',J�/� C�++r�+�+� from cG to`�� ft.__, yards�_ bags
___ from to ft. yards ___ bags
__ __ from to __ ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property7 [;Yes No How many?_
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
��R�'��D This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
V is true to the best of my kno�vledge.
FEB 4— 2013 � scoa��� ISe1l. Drillirts C,o., r�. z�Q�
Licensee Business N me License or Registration No.
ff
CITY O�ORONO _ --,� f � f - / � - 1.�
, ��, � ,
ifie0 Represenfative Si n�hire Certified Rep.No. Date
. .- �.
�OCAL COPY H � — ---- ti�-�- Rf� �s �iC�Y��..+ _
3 0 9 6 4.� Name of Person Sealing Well or, oring
HE-01434-13 IC#140-0423 5n2R ¢