HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 5 3 3�7
County Name
WELL AND BORING SEALING RECORD Minnleso a�Unique Well No.
��� i� Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank i�not knownf
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 3 26 3�A Z(� f.�C'T� o t..,
.
GPS Latitude degrees minutes seconds Depth Before Sealing � 7 ft. Original Depth k.
LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ��Multiaquifer
WELUBORING �Measured �]Estimated Date Measured__ ._ -
,� �Water-Supply Well ❑Monit.Well �
' Show exact location o �ell or boring Sketch map of well or boring .
in section grid with"X" location,showing properry I�Env.Bore Hole ❑Other �Q ft. ;�ibelow ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
' --'---- �-----'—---'-- � �Ste
; j j j j �. � el ❑Plastic ❑Tile �. th
' ]O er
� --�--- --�--- ---�-----'-- WELLHEAD COMPLETION
W � � � � E I
, � � � � Outside: ❑Well House ❑At Grade Inside: �asement Offset �
'h Miie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit
- .--- --,--- -�- --:- 1
❑Well Pit ❑Buried
S ❑Other
I , qt
�1 Mile� 1 �-- 1�, � �,��-q�,. ❑Othe�
� �.>`'._ 1. a.,.. �-4.
PROPERTY OWN R'$NAME/COMPANY NAME CASING(S)
I�tichae�1Stachia Fe Diameter� � Depth � Set in oversize hole? Annular space initially grouted?
Properry owners mailing address if difterent Ihan well location address indicated above � � �—,
in.from� b�R ,�Yes �No ❑Yes ❑No (_]Unknown
in.from to R (J Yes jJ No ❑Yes ❑No ❑Unknown '��
�
in.from fo ft. ❑Yes ❑No j]Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f
r �
Well owner's maiiing address if different than property owner's address indicated above Screen from��to��ft. Open Hole from to ft.
OBSTRUCTIONS
i
❑Rods/Drop Pipe �J Check Valve(s) ❑Debris ❑Fill �j No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe
FORMATION
PUMP
It not known.indicate esfimated formation log from nearby well or boring.
/-t, � Type
� ❑Removed �Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists I J Annular Space Grouted with Tremie Pipe �Casing Perforation/Removal
in.from to fl. ❑Perforated �]Removed
i
in.from to ___ft. ❑Perforated '�Removed
� Type of Perforator_ __,__ _ _
❑Other
�
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
4 t �
Grouting Material N��/ C�dJ��iC!/from_�_,_ 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 How many?
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 knowledge.
Dc� Stodala taell Drillin� Co, Inc. 169I
Contractor Business ame License or Registration No.
i
��'`J� � C�, G{r�
rese tative Signatuie Certilied Rep.No. Date
J=J,�/\,/Y'.Nti���.QJ��Y`�--
LOCAL COPY H 2 5 3 3 8 7 y�
Name ol Person Sealing Well or Boring
HE-01434-09 IC�140-0423 ,. s/osR