HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 9 515 6
Counry Name
WELL AND BORING SEALING RECORD Minneso a�Unique Well No.
Hennepin Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank�il no�known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
oc�o �.�� 23 2o sE zar� �. mAN 1 �
r
GPS Latitude degrees minutes seconds Depth Before Sealing � ft. Original Depth ft.
LOCATION: Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer Q
W L/BORING �Measured ❑Estimated Date Measuredy�_�r'
Water-Su I Well �
pp y ❑Monit.Well ,�/
Show exact loca ion of well or boring Sketch map of well or boring Env.Bore Hole �/� '�,�b ❑above land surface
in section grid with"X." perty ❑ ❑Other ft. elow
lines,roads,and b Idings.
N CASING TYPE(S)
y+ �Steel ❑Plastic ❑Tile ❑Other
, , , , � ��Y
--'--- --�--- ---`-- ---�-- WELLHEAD COMPI.ETION
W ; ; ; ; ET
� � � � Outside: ❑Well House ❑At Grade Inside: �Basement Offset
'h n4iie �Pitless Adapter/Unit �Buried ❑Well Pit
--;--- --�--- ---�-----:-- I •--� d
; ; ; ; 1 ❑Burie
S `���"j�Y' j'i.�C�-.-�_.z.� ❑Well Pit ,]Other
�—i Mile� � [_]Other _
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diame r�� � Depth � Set in oversize hole? Annular space initially grouted?
rope y ow 's mai ing a ress if diflerent than well location address indicated above �in.ffOm �� to�. ❑YeS �o ❑Yes ❑No ❑UnknOwn
in.trom to ft. ❑Yes ❑No ❑Yes ❑No [�Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � j � �
Well owner's mailing address if different ihan property owner's address indicated above SCreen from /v • to�ft. Open Hole from_ to ft.
OBSTRUCTIONS
�ods/Drop Pipe U Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) J�-��'�-�/�- /".��-"— � �umD
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
PUMP 5 u(3 f-,v r� p
If not known,indicate estimaled formation log from nearby well or boring.
' /1 Type__
t"'� ZJ r�emoved ❑Not Present ❑Other
!'
�ME,/THOD USED TO SEAL ANNULAR SPACE BE7WEEN 2 CASINGS,OR CASING AND BORE HOLE:
I XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
T�
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
❑Other
GROUTING MATEFIAL(S) (One bag of cement=9�Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material/V"»�"!`y 4.�-/�'-�f'rom � to �v yards� bags
__ from to ft. yards bags
__ from _ ro ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [_J Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.Ttie information contained in this report
RECEIVEDis true to the best of my knowledge.
JU L - 5 2 011 � �todola Well Dci3lic�; Co�._Tr�. �69Y--
Licensee Busine Name � License or Registration No.
.---
CITY OF ORONO �- � �� � �
ili pre e ative Signat r� Certilied Rep.No. Date
29515� �
LOCAL COPY �"� � �'���Y'��"
Name of Person Sealing Well or Boring
HE-01434-12 IC#140-0423