HomeMy WebLinkAboutwell info � .""=%;�'',
MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ���
.OR BORING IOCATION yyELL AND BORING SEALING RECORD sea''"9"°. i H _
�ry Name Minnesota Unique Well No.
denn�pin Mmnesota Statutes.Chapre��031 or W-series No.
M1.ev.w�x n�rn x�w�� ------
ownship Name Township No. Range No Secuon No. FracUon�sm.-i Ig.) Date Sealed Date Well or Boring Constructed
Orono 11? 23 18 , ,. 5/9100
Numencal Streel Adtlress or Fne Number and Cyrty of Well or Bonng Location s�
�.�8.�.. Fa�ernes� pQi�tr �d• d�On� Depth Betorr,Sealing 9v _R Original Depth 96 n
Show exact location of N�ell or bonng Sketch map of weu or bonng AOUIFER(S) STATIC WATER LEVEL
in section gnd with"X". N � locatwn, showing property �S�ngle Ayurter � MultiaquAer
lines,roads.and buildi s.
N WELUBORING �easwed ❑ Esumatetl
� � � �
[zWater Supply Well ❑Monit.Well
-�- -�— � 7
❑ Env.Bore Nole ❑Other _ �•_tt. [j'�ielow ❑ aDove land surface
W --�- - -- - -- -- -- E (� CASING TVPE(S)
� � �
� � � N
—�- -�- -;— --�— � �( F / [�]LStee� ❑ Piastic �Tile ❑ Otne�
I I }2mile �� f
--�- -�-- -�-- --1-- � IN ;' CASING(S)
' S ' \ k' � / � Diameter Depth Set in oversize hole9 Annular space initially grouted?
��"" / bt
�i mee� Jl f ,' ��(-' � in.Irom� to� fl. ❑ Yes �lo ❑ �es ❑No ❑ Unknown
� 1
PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
�cti Christer�son
Property ownei s mailmg address it ditteren�than well locauon address indicated above. in.hom to fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN MOLE
Screen from �� to 7� R. Open Hole from to R.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Dro Pi e ❑Check Valve(s) ❑ Debris
[][ p p ❑ Fill ❑ No Obsiruction
Well owner's mailing address il ditterent than property owner's address indicated above. Type of Obstructions(DesCribe) ,�u�,� and ��p�
Obstructions removed? �Yes ❑ No Describe
PUMP
Type ��t'r
GEOLOGICAL MATERIAL COLOR �ARDNESS OF FROM TO �emoved ❑ Not Present ❑ Other
FORMATION
If not krawn,iMicate estimated tormation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
C�Jo Annular Space Exists
ci r i f t � � ❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to fl. ❑ PeAoraled ❑ Removed
in.from �o h. ❑ Pertorated ❑ iiemoved
Type of peRorator
❑ Other
GROUTING MATERIAL(S) (One bag oi cement=941bs.,one bag oi bentonite=50 Ibs.)
Grouting Material �'ortlaAd from �� to � fl. yards � bags
irom to ft. yards bags
from to ft. yerds bags
from to__ tt. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes p No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this report is
true to the best of my knowledge.
8E5 Wei3 �ril2ia� 2'7276
Contractor Business Name License or Regishafion fro.
�
�. �_
Aufhonzed R e've 'nafure � - Date
Jam�s Lea
:_.i ji;p�,. ;��j�v u ����j� Name ol Person Sealing Wel/or Bonng
fl �f