HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„' r� �^
County Name
WELL AND BORING SEALING RECORD M nneso aoUnique WeII No.
Minnesota Statutes,Chapter iO3! or W-series No. x
(Leave Wank ii not known)
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Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed _
(� � � ,�i'� „ '
GPS LOCATION-decimal degrees(to four decimal places) CITY OF ORONO
Depth Before Sealing ft. Original Depth ft.
Latitude Longitude
A IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
�{ 'T � � �. 7� W UBORING Measured ❑Estimated Date Measured
l 7� OCttil �C�"? C CC)?1f} �� >���s
Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or b rin
in section grid with"X:' location,showing prop ty., ❑Env.Bore Hole ❑Other �tt. �'�elow ❑above land surface
N lines,roads,and buildi s.;:, CASINGTVPE(S)
`
_ --'-- --i-----`-----'-- ' ��
i �X Steel ❑Plastic ❑Tile ❑Other
> _,___ __a___�_____;__ WELLHEADCOMPLETION �
W : : : ; ET �
� � � � Outside: ❑Well House ❑At Grade Inside: Basement Offset
'h Miie Buried ❑Well Pit
� .
�.. ; T ' ; itless A p r/Unit � uried
1 � ❑P da te
; ; ; , \" �]we��Pit ❑s
, S +�� ❑Other
,: ��nniie� \�3 ❑Other
3 S
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� �J r G Diameter Dept Set in oversize hole? Annular space initially grouted?
Properry owneis mailing a dress if different than well location address indicated above �in.frOm_� to�ft. ❑Yes �No ❑Yes ❑No L]Unknown
? in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
h WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if different than properry owner's addiess indicated above SCre2n frOm_��to f Pr- ft. Open Hole f�om to ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
\
Type of Obstructions(Describe) � (�+�
!
# GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
5 If not known,indicate estimated formation log from nearby well or boring. PUMP �/
j' Type � �'�G 1�- �
t-` �� l T �� �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.trom 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 MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material fV� C' T (?2a"�iC�'i#rom__�� 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? [j Yes No 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. y
T)on Gtoclola ���ell Drillin� Co,. Ir:c. 1t7�1
Licensee Business Name License or Registration No.
/
o�'/� �` �'�br��., 9' �` / �
QBthlrecYR p�ve S�gr�ture Certified Rep.No. Date �'
_ �
LOCAL COP`1 " 3 416 9 6 ��--�- �
Name of Person Sealing Well or Boring
HE-01434-14 ID#53159 5/13R