HomeMy WebLinkAboutwell info wELL Oq BORING LOCAT�ON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i � �
WELL AND BORING SEALING RECORD Sealing No IH 1�. ,_:9�9
Counry Name MinnesO:a Unique No. � - �
(� Mmnesota Statutes,Chapter 1031 or W-senes No. �
f?��i�� in ILeaveDianpAnotknown� _..
Township Name Township No. Range No Section No. Fracaon�sm.-s Ig.) Date Sealed Date Well or Boring ConsVuctetl
�rono I 7 2 2 12 tJt�17�� 3 /1'}f1� �}
Numerical Street Address or Fire Number and City of Well or Bonng�ocanon / � �
3555 Fredrick Ave, Orono 55391 DepthBetoreSeahng /37 R O�iginalDepih �_h
Show exact Iceatlon of K•ell or boring Sketch map of well or bor�ng UIFER(S) STATIC WATER LEVE�
m section grid with"X". � lotahon, showing property Single Aywter � Mulhaqwter
I es,roads:;antl buildings
N f'��,_y,..��.�� <�-��...� `�..l�s�iL WELVBORING Measured ❑ EsUmated
Water Supply Well ❑Monit.Well �
❑ Env.Bore Hole ❑Other _ � ft. �elow ❑above land surtace
I I I I _._...,..__..
W --r- -�-- - -- --�-- E _ CASING TYPE�S)
�
� � � +�
�
� � � �
—�- -�- -i-- --i-- Steei ❑ Plastic ❑Tile ❑Omer
'F mrle
--�- ' I ' � .._. CASING
-�-- -�-- --i--
_____ Dia�tql Depth ( Set in overs¢e hole7 Annualar space initially grouted?
S
��m�� in from � to /33 tt ❑ ves �No ❑ Yes ❑No ❑ Unknown
PR PER OWNER'S NAME m.from ro ft. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
�h-�Llis Anderson G7I-9a52
Properry owner's maihng address if diHeren�than well location address indicated above. in.hom to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE �
I j� �
Screen from�to L� h. Open Hole from ro H.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Dro Pi /� �� s�
p pe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction
Well owneYs mailing atldress it diflerent than property owner's address indicated abova. Type of Obslructions(Describe),,,,`N1U!��1� • -.:('�'� 4" /""�//!/� �
Obstructions removed? �Yes ❑ No Describe
PUMP /�
7ype S�G �'�..1MP
OEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
11 rat krawn,indicate estimated fortnatbn log trom nearby well or boring. METHOD USED TO SEAL ANNUUR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �No Annular Space Exists
��,J { �.�� :�:"1
❑ Annular space grouted with tremie pipe
_�' � ❑Casing Perforation/Removal
in.from to ft. ❑ Pertorated ❑ Removed
in.from to fl. ❑ PeAoreted ❑ Removed
Type of peAorator
❑ omer
GROUTING MATERIAL(S)
Grouting Material�F���,�"'^�1rom � to�L 11. yards �.�e_ bags
from to h. yards begs
from to h. yards begs �
from to__ ft. yards begs
REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINCaS
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 accordence with Minnesota Rules,Chapter 4725. The information confeined in Mis report ia
true to the best of my knowledge.
Don Stodols WeZl Drillfng Co. , Inc. 27I72
Contractor Business N e License a Regishation fio.
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utho'ed Representative Signetwe.. Dafe
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�` �.'7-.!'v �ati,_,/C?,..L�Y.`..,
Name ol Pers6n�Sealing Well or Boring
LOCALCOPY H
HE-01434-04 8�9$R