HomeMy WebLinkAboutwell info�"
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ; 13 4 9 3 6�
WELL AND BORING SEALING RECORD Sealing No H
County Name Minnesota Unique No. --
Minnesota Statutes,Chapter 1031 or W-series No, �
ILeave blank it not known7
Township Name Township No. Range No. Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Boring Constructed
Orono 1I8 23 3b 3�-Ot1 ' � �i
Numerical Street Address or Fire Number and Ciry of Well or Boring Location q �' !
4 M wo d �d 4rono Depth Before Sealing �G� k Original Depth �
Show exact location of well or boring ��39�ketch map of well or bonng ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". cation, showing property Single Ayuifer ❑ Mul6aquiter
N �� lines,road and Id ngs.
�.���.1.���-v�- -.�:."� WELUBORING Measured ❑ Estimated
� `�—' Water Supply Well ❑Monit.Well M �
-- - - -- -- -- --i-- � f��1
pa �� ❑ Ern.Bore Hole ❑Other ___ ""'-'� ft. ,�below ❑ above land surface
W --'r -i— -i— --i— E _. ��1 ,.,,y. CASING TYPE�S)
�
� � �
� � �
-;— -�-- -;-- --;-- �Steel � Plastic �Tile � Other
� � ' � �mne
' ' ' ' � CASING
---- -�-- -�-- --1- �_
.._..___..
Diameter f Depth � Set m oversize hole? Annualar space iNtially grouted?
S !
�r mae� � ^Y y '� � in.irom� to�fl. ❑ Yes �No ❑ Yes ❑No ❑ Unknown
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
s
Property owner's mailing address�t diHerent than well loca6on address indicated above. in.from to tt. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
/�/�1 /
Screen from_�L to�� ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction
Well owner's mailing address if ditterent than property owners address indicated above. Type Of Obslructions(DesCribe) `^���'"��`� / ��� ¢ ���
Obstructions removed? ,�TYes ❑ No Describe
PUMP
Type
GEOLOGICAI MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �
� �No Annular Space Exits
, �t n,,r._ : .� i./�i.
❑ Annular space grouted with tremie pipe
�� ❑ Casing PeAoration/Removal
in.from to (1. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type oi perforator
❑ Other
GROUTING MATERIAL(S)
' �
/
Grouting Matenal�"=����'����6m Q ro� ft. yards � bags
from to tt. yards bags
from to ft. yards bags
trom to__ tt. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
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.
Doa Stodola Well Drilling Co. , Inc, 27172
, Contractor Business Name License or Registratlon 170.
�t i� 1 3 199% �-- ___ ; . _-
�% ` r�' �'' ..�' -/.--�- %'.��
� � � �Authonzed Represenfalive Signafure I Date
_ _ ,,-�.� ..��'� ..�z�.�, �
13 4 9 3� Name ol Persorv Sealing Well or Boring
LOCALCOPY H '
HE-01434-03 2/97 R