HomeMy WebLinkAboutwell info WELL oR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 119 2 9 2
County Name
WELL AND BORING SEALING RECORD M nn'e9oNa Unique No.
H't..'T2i14�li� Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed
Orono i i 7 24 7 ,� ,, ti �/23/9 i
Numerical Street Address or Fire Number and City of Well or Boring Location
1295 Elm�►oc�d p1Y£ Depth Before Sealing �� ft Original Depth g� ft.
Show exact location of well or boring Sketch map ot well or boring ADUIFER(S) STATIC WATER LEVEL
in section grid with"X". �� � location, showing property �Single Aquifer ❑ MWtiaquffer
i � lines,roads,and buildings.
N WELUBORING �]Measured ❑ Estimated
_Y_ _ _ _l__ _l__
' Water Supply Well ❑Monit.Well
{ � ❑ Env.Bore Hole ❑Other �0
� � ft. �below ❑ above land suAace
:
--i-- '�-- 'i-- --i-- ' : � k
W � � E ` CASING TYPE(S)
� � � � � � i..,,�.
--�- -�-- -�-- -"'�-- Steel Plastic
❑ ❑Tile � Other
u mi�e �
--�- -�-- --i-- --�-- � -- CASING
Diameter Depih Set in oversize hole? Annualar space initially grouted?
S
�—i m��e—�e _� in.from� to� ft. ❑ Yes $�No ❑ Yes ❑No ❑ Unknown
PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
Properry owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
Screen from 7� to �� R. Open Hole from to R.
OBSTRUCTIOWDEBRIS/FILL C�r(OF
WELL OWNER'S NAME
[[�Obstruction ❑ Debris ❑ Fill ❑ No Obstrudion � �
ORON
�� ' fl�`'„r',r--'- i
� ,
Well owner's mailing address if different ihan properry owners address indicated above. Type of Obstruction/DebriS/Fill � �
Obstruction/Debris/Fill removed? [][Yes ❑ No
PUMP
TYPB ��t �u�� � 3 1��7
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �'�emoved ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASI G AND BORE HOLE:
n Q 0 OCNo Annular Space Exits
citift v c�
❑ Annular space grouted with tremie pipe
❑ Casing Pertoration/Removal
in.from to ft. ❑ PeAorated ❑ Removed
in.from to ft. ❑ Pertoreted ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
Grouting Material��r�13I1 t� from �� to 0 ft. yards L bags
from to ft. yards bags
from to R. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes �GNo
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in eccordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is
true to the best of my knowledge.
R.�.S. We:ll Uril2in� 27275
Contrador Business Name License or Regisfretion No.
�,�' t � �,'"�_.-. 1 �
i ,.._�_-,": �:� ^!. �'l�- � 1,
� � _ —� �/,��1/ �
Authorized Representative Signafure Date
James Lea
LOCAL COPY H 119 2 9 2 Name ol Person Sealing WeII or Boring
HE-01434-02 10/95R