HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H � ��� (� �
County Name
WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. �
����t]p��,(Z Minnesota Statutes,Chapter 1031 °QaW se�ieskNo.
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
arono 117 ?_3 Zl �' S'�T ?�•� r �� !�
GPS LOCATION-decimal degrees(to four decimal places) �
Depth Before Sealing ��� tt. Original Depth ft.
Latitude__ _ Longitude
A�UIFER(S) STATIC WATER LEVEL
Numerical Stre �e ire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer e�n/�n L d
W UBORING Measured ❑Estimated Date Measured.l/�/��_ ��+
���r' h:tl I ^v� �l'Orlt'� �?�i�1 �yyater-Supply Well ❑Monit.Well i
Show exac�t location of well or boring Sketch map of w,eJ(�r bo�ng / ,r� �,r{
in section rid with"X:' location,sho�p��f� ert ❑Env.Bore Hole ❑Other �f'.�*/ ft. /p��below ❑above land surface
N ��line , ds}��n i dings.
CASING TYPE(S)
; ; ; ; j
--�-----�-----�-----•-- t �
j j ; j f Steel ❑Plastic ❑Tile ❑Other
� � , � `
--'--- --'----"�-----�-- ELLHEAD COMPLETION
� � � � t W
W : : : : ET
__�___ __�______�__ ___�__ Outside: ❑Well House ❑At Grade Inside: �asement Offset
, , , , 'h Miie itless A p dUnit ❑Buried ❑Well Pit
, , , , � ❑P da te
--�----T---�-- - '
❑Well Pit ❑Buried
S
❑Other
�1 Mile-� �( • ❑Other
71 ..t' %� �>>R
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� �t Diame ef s � Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above L
in.from�� to 22� ft. ❑Yes � I No ❑Yes ❑No ❑Unknown
in.from 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
t /
Well owner's mailing address i�diflerent than properry owneYs address indicated above Sc�een from�__._-�._to_��ft. Open Hole frOm to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) �f Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe l�.l� /"LI'� t �(//yf/-�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe
FORMATION
PUMP �'}
If not known,indicate estimated formation log from nearby well or boring. Type .,,)�J� (`U��
�� f }�
�'� 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 �� No TN#
GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.)
Grouting Material!v,�^fy/ C 6m�� from E� to <C.. ft. yards� bags
from to R. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATq�.p�G��TI�S�ING Other unsealed and unused well or boring on property? ❑Yes o How many?
tCG G V c��
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The�information contained in this report
M�� O � �`-�, is true to the best of my knowledge.
_E
�r. �t�r?ola t�ell T)rillin;�; Go. I?jc. 158�!
C�T1(OF ORONO Licensee Business Name , License or Registration No.
� �f���� ��. I �� f �
....�` ,-.' ,. ✓� r
�ertilled F?e�resentative Signature Certified Rep.No. Date
"'� ''_ ,� � J� �.�, �
H �43 C � ��,.,-, .._...
LOCAL COPY .�.: �l,1� � fi Name ol Person Sealing Well or Boring
HE-01434-14 ID#53159 ,.. Sn3a