HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Borirtg H 2 g 6 3 0 5
County Name
WELL AND BORING SEALING RECORD Menn�e9oNa Unique Well No.
�pin Minnesota Statutes,Chapter 1037 or W-series No.
(LEdve bldnk il no�known)
Township Name Township No. Range No. Sec[ion No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed
E?rono 117 23 QZ S'� � 9W / `/v,v,�
.
GPS Latitude _ degrees minutes seconds Depth Before Sealing �� ft. Original Depth _ ft. �
LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVE
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer � ,/t A'�
12S5 Dicloec�oc� St, 0� WELL/BORING �Measured �_J Estir�ated Date Measured �►`�� iy�r
�Water-Suppiy Well ❑Monit.Well � �
Show exact location of well or boring Sketch map of well or boring ��
in section grid with"X." I ation,showing proper4� � .�Env.Bore Hole ❑Other ,_._ ft. �below ❑above land surface
N ,���.l��ads�n i ings}...i CASINGTYPE(S)
'GY'
r
--'-- --'--- ---'-----'-- �
�.Steel �Plastic �J Tile ❑Other_ ___
--'--- --�--- ---`-- ---`-- WELLHEAD COMPLETION
W : : : : ET �
� � _;_____;_ � Outside: [:Well House �]At Grade Inside: ❑Basement Offset
'h Mile Buried ❑Well Pit
--�-- -T----�-- ---�-- less A p dUnit � d
1 �pit da te
❑Well Pit ��Burie
S ❑Other
�-1 Mile—� ❑Other
PR�E�Tx QWNE�S 1�4ME/COMPANY NAME CASING(S) �
�� �K> '� Diame er r Depth � Set in oversiz�hole? Annular space initially grouted?
Property owner's mailing address if diflerent than well location address indicated above ���rin.from Q to �� ft. ❑Yes �No ❑Yes ❑No ❑Unknown
1I401 �ey Rd 3
aeupl�.L�� I� 553Ei3 in.from [o ft. ❑Yes [�'No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑��,No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
!'�t s �
Well owner's mailing address if different ihan property owner's address indicated above SCreen from / r t0�ft. Open Hole frOm_�to ft.
OBSTRUCTIONS
;�Rods/Drop Pipe ❑Check Valve(s) I ��.Debris [Fill ',_,No Obstruction
Type of Obstructions(Describe) �Rl/�_� �� 4 �n
T
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe �
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
r Type_�V � L�(� �
� .�'-�` � �� Removed ❑Not Pr sent ❑Other
rf �HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ��Removed
in.from to ft. ❑Perforated �,Removed
Type of Perforator
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one b8g of bentonite=50 Ibs.)
I r
GroutingMaterial�L/QT��L trom � to� ft. yards� bags
from to ft. yards bags
from to�_ ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o i How many?
RECEiVED LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knawledge. �
JUL -5 2011
Dan Stvdola tie22 illfr� Co., �nc. i591
CITI(OF ORONO licensee Business Na e License or Registration No.
�.l��� y� £f� � //
�
r' presentative Sign ur � Certil'd Rep.No. Date
LOCAL COPY H ,--- _�Y�/•1tS Y�
2 9 6 3 0 5 Name of Person Sealing Well or Boring
HE-01434-12 IC#140-0423 �� s/osR
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