HomeMy WebLinkAbout2017-Well & boring sealing record /j WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 5 2 2
County Name WELL AND BORING SEALING RECORD Minneso aSealinoUnique Well No. 6`{
Minnesota Statutes,Chapter 1031 or W-series No.
is on rta oii111
Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed
0rouo 0 F.1i7 c3 Lu ''.—.. /(—.) ,/
/26 /7
GPS LOCATION— decimal degrees(to four decimal places)
Depth at Time of Sealing 22/ ft. Original Depth ft.
Latitude Longitude
AOUIFER(S)' STATIC WATER LEVEL '
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
WELL/BORING Measured Date MeasuredSR1 ffl& 'r El Estimated
'` . '" r* . rz s )4Water-Supply Well ❑Monit.Well rr
Show exact location of well or boring !4., Sketch map of well or boringn
in section grid with"X.' 4 1 location,showing property El Env.Bore Hole EI Other 57 ft. below ❑above land surface
lines,roads,and buildings.
N CASING TYPE(S)
QJ
yil,y %Steel ❑Plastic El Tile ❑Other `{ �`Ep�
V
---i- - --'------t---- - �',. 1 WELLHEAD COMPLETION
W E
T Outside: Pitless Adapter/Unit 10 At Grade Inside: EI Basement Offset JAN
201
h Mile �' II] Pit ❑Buried ❑Well House
r-- I ` U ❑Well Pit
1 by El Other ❑Buried
CITY OF ORONO
5
1 Mile (�J ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
a Diametar , Depth Set in oversize hole? Annular space initially grouted?
tismaiingad ieli i3$til is u�;rTZi
Property owner's mailing ad ress i di Brent than wenIota n address indicate above in.from2IL to ! ft. ❑Yes gNo ❑Yes ❑No ❑Unknown
1611U ''iinaetonka blvd.
t ayzata, kA .
551 in.from to ft. ❑Yes ❑No El Yes ❑No LI Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r
Well owner's mailing address if different than property owner's address indicated above Screen from 2�? to ftI . Open HOIe from t0 ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑De�briss El Fill El No Obstruction
Type of Obstructions(Describe)
....//V4f/L.1 /�? - (/LJ/�/
GEOLOGICAL MATERIALI COLOR HARDNESS OR
FORMATION FROM TO Obstructions removed? XYes ElNo Describe
If not known,indicate estimated formation log from nearby well or boring. PUMP
El Not Present Present,Removed Prior to Sealing LiOther
7 c)rC;F 1 iz+ Type 5U ('')( l�U(Yi()
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
as g Diameter
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
VARIANCE ,,,,,,������//////
Was a variance granted from the MDH for this well? El Yes , No TN#
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material A/e ` Ic_"j1.l9from C/ tq_ZEZ ft. yards /8 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 XNo 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.
LJ.i S i'ubULA WELL DkILLIAG 0-.). , 1si9. 1691
Licensee Business NameLicense or Registration No.
J5o 1f�. ' I '/
rt.led p sentative Signature Certified Rep.No. Date
LOCAL COPY H 3 5 2 26 /�
`tName of Person Sealing Well or Boring
HE-01434-15 ID#53159 8n6R