HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD Sea�ing No. H 11016 2
County Name Minnesota Unique No.
Heane in Minnesota Statutes,Chapter 1031 or W-series No.
� (Leave blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Orono 11? 23 7 � � � 8/30/96
Numerical Street Address or Fire Number and City of Well or Boring Location
Z�Q1 North Ar� Drive DepthBeforeSealing g� ft. OriginalDepth '��� ft.
Show exact location of well or boring Sketch map of well or boring ApU1FER(S) STATIC WATER LEVEL
in section grid with"X". � `� location, showing property �ingle Aquifer ❑ Multiaquifer
��� lines,roads,and buildings.
N WELL/BORING �vleasured ❑ Estimated
[�ENater Supply Well ❑Monit.Well
_ _ _Y_ _l__ __l__
❑ Env.Bore Hole ❑Other �r� ft. ❑ below ❑ above I nd s�rface;'
W --�- -i-- -i-- --i-- E CASING TYPE(S) 5 �
-r- -�-- -;-- --�-- � �teel ❑ Plastic ❑Tile ❑ Other
%mile ,,,.,__.�_�/�---^-�-�
-�-- -�-- —�-- --�-- � ��_�� CASING �
Diameter Depth Set in oversize hole? Annualar space initially grouted?
L� S
pl��mi�e� � in.from.�— to�fi_ ft. ❑ Yes [�No ❑Yes ❑No ❑ Unknown
I
PROPERTY OWNER'S NAME in.from to ft. ❑Yes ❑No ❑ Yes ❑ No ❑ Unknown
Property owner's mailing address if different than well location address indicated above. in.ffom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEN/OPEN HOLE
Screen from��to�� ft. Open Hole from to ft.
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill [�No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill
Obstruction/Debris/Fill removed? ❑ Yes ❑ No
PUMP
Type
GEOLOG�CAL 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:
d r i f t O �O �No Annular Space Exits
❑ 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)
Grouting Material ��'++►�-� �++� from �.�_ to�_ ft. yards � bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes No
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.
Contracto� usmess Name License or Registration No.
��, 1 �Ji� � �/�,/`:I�/�,—
Authonzed p b`�ntaGve �gn ate
Neme o erson ea mg e I or Boring
LOCAL COPY H �� �. 016 2
HE-01434-02 10/95R