HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �Q����
County Name
WELL AND BORING SEALING RECORD Mennleso a�Unique WeII No. `�
Minnesota Statutes,Chapter 103/ or W-series No.
(Leave blank il not known)
Towns ip ame ownship No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Orono lI 3 '� �4t S6�
,� , ;
�� GPS Latitude _,_.__, degrees _ minutes _ seconds Depth Before Sealing �� ft. Original Depth k.
LOCATION: Longitude___ degrees_ _ minutes seconds ��FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ' ingle Aquifer ❑Multiaquifer Q�y�M! 1�/1�
� I�Bf �+�' ��Q�' � S�� 1yF�UBORWG �easured ❑Estimated Date Measured�����`r� �-�Y
�:j�vater-Supply Well ❑MoniL Well
Show exact location of well or boring Sketch map of well or boring ��/�
in section grid with"X." location,showing property ❑Env.Bore Hole ❑Other � .� ft. �elow ❑above land surface
lines,roads,and buildings. -
N CASING TYPE(S)
'�� --'-----'------`-----'-- ' .
�Steel ❑Plastic ❑Tile ❑Other _
; � I I �� �.;:
--'-----�-----`-----'-- �' WELLHEAD COMPLETION
W � � � � ET �/
;.� ' ' ' ' I Outside: �]Well House ❑At Grade Inside: JlBasement Offset �i
—-----------—--- — �I-'�
� , , , r Mile rtless A p dUnd ❑Buried �f Well Pd
�� ❑P' da te
--�-----T—---�----�— [J
I Buried
1��. ❑Well Pit �
5
❑Other
�—1 Mile� +�' ❑Othef
PROP�R�O�ER'S NAME/COMPANY NAME CASING(S)
� Dia�te�� �� Depth� �� Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if tliflerent than well location address indicated above in.from to ft. ❑Yes �1No ❑Yes _]No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes i]No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE� �
Well owner's mailing address if diflerent ihan property owner's address indicated above Screen from +�1 to�ft. Open Hole from to ft.
i
OBSTRUCTIONS �
�Rods/Drop Pipe ❑Check Valve(s) �Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)C.�<</_.�T � �rl✓/Ll�e�' / -�� ¢ �L �
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [�es ❑No Describe •.�"'��'� �v f ��'/�tGi�I J • �' ~ � �s
FORMATION
PUMP
If not own,indicate estimated formation log from nearby well or boring.
Type
` � ��I`.Removed ot PreseM [;Other
A1ETjdOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
dno 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 ___
—I Other
GROUTING MATERIAL(S) (One bag of cement=94�s.,one bag of bentonite=50 Ibs.)
Grouting Material("���� �`//�/"�from � to �� ft. yards_ � bags
from to ft. __ yards bags
from to ft. _ yards bags
� OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING Other unsealed and unused well or boring on property? �__J Yes [� lo 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.
� Don Stodola �ell IIcilling Co,. Inc. 1691
Licensee Business Name - � License or Registration No.
/J- � - O �'!
i e enta�e i atur� Certilied Rep.No. Date *
'. •.. ��--�+ �, `
LOGNL COPY H f�Y Z 1 i.ri. —____ _ _— --- �`�'�3�V�. +�`"t'\`.l
Name of Person Sealing Well or o�ing �
HE-01434-11 IC#140-0423 �� 2ioaa
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