HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � �� ^� � /�
County Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. � L}
Minnesota Statutes,Chapter 1031 or W-series No.
I�r�r�e in «ea�a b�a�k,�o,k�aw�>
Township t�ame Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Cons[ructed
�`rono 117 23 21 i� S�`� ]�tTi ��
GPS LOCATION— decimal degrees(to four decimal places) /
Depth Before Sealing Z,�� ft. Original Depth ft.
Latitude Longitude
A UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer d /��
271� v?�.l" �V� �CC}L10 55331 W LL/BORING Measured ❑Estimated Date Measured��1��' �.I'T�
' Water-Supply Well ❑Monit.Well /
Show exact location of well or boring Sketch map of well or boring
in section grid with"X:' location,showing property ❑Env.Bore Hole ❑Other ��ft. �below ❑above land surface
N lin , -,and buildings. CASING TYPE(S)
, � ,
--'--- - � ---`-- ---'-- o
-'---
; ; j j tiy,,a-`� Steel ❑Plastic ❑Tile ❑Other
--�-----'--- ---�-- � ''y WELLHEAD COMPLETION
W ; ; ; ; ET .
Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
'h Mile �Pitless AdaptedUnit �uried ❑Well Pit
--�-----T— ---;-----�- uried
- ❑B
�"`�.,, []Well Pit
1 ' S ' , �'�- ❑Other
�-1 Mile� �' -�:.i�,q � .�i� ❑OthOf
�... ."J."t„''�
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
�tanle - `�unkel�ri Z Diar�e��� �r Depth�� � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above y in.from� to ft. ❑Yes ,�No ❑Yes ❑No ❑Unknown
630fi Fden Pra�rie Rd r in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Eden Prairie, M�.T 5534b
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if ditterent than property owner's address indicated above Scre2n trom ���� to ��, ' ft. Open Hole f�om to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)�,,,f A/,d1�I�. �j—� 4 �(J�/f�
1
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring. PUMP �
` Type `7V� �U��
-"'`� � � Removed ❑Not Present ❑Other
�..� METHOD USEDTO 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
VARIANCE
Was a variance granted from the MDH for this well? �]Yes o TN#
GROUTING MATERIAL(S) (One bag af cement= 4 Ibs.,one bag of bentonite-50 Ibs.)
/✓�A%�L�!?��T '� � �
Grouting Material from� to�t ft. yards bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIF L Other unsealed and unused well or boring on property? ❑Yes�No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
MAY 0 91016 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 knowledge.
C►lY OF ORONO Licensee Busine�ss Na�m�0�1 t�Te1Z Drillfn�; �i0�• 11�•
License or Registration No.
,... A �; . / t.�� � I' �l,lJ --
y::. �' !
Ce�ed Representative Signat e Certilied Rep.No. Date
�_.�
" � 3 ��9� ��
LOCALCOPY '�,,'y.v.`", . ;�y E ��Y°�.
Name of Person Sealing Well or Borinq�
HE-01434-14 ID#53159 . 5n3R