HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +f ����� �
�- WELLOR BORING LOCATION yyELL AND BORING SEALING RECORD Sealing No. �H_y
Counry Name Minnesota Unique Well No. r — �
M�nnesota Statutes.Chapter 1031 or W-series No. I
?Henne in M1.�.d�„�«k��, �-
Township Name Township No. Range No. Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Bormg Constructetl .
Orono II7 23 07 43�-4�31'� p .,
Numencal Street Address or Fire Number and CRy of Well or Bonng LocaGon e�/.�r A� �
4 36 5 N Sho re �t� ��0�� 5 J 3 V Y Depth Before Sealing fCJ tt Original Depih /� ft
Show exact Iceation of v.•ell or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL
in section grid wrth"X`. locanon, showing property Single Aywfer � MultiaquAer
31ine5,roads,a d ildings.
. ry .� _ ,,�� 1,.. � ���, , yVElUBORING �Measuretl ❑ Eshmated
� ���Water Supply Well ❑Monit.Well /
s ❑ Env.Bore Hole ❑Other _ _�ft. �below ❑ above land surface
�-- � W --�- -i-- -i-- --i— E . ..___.....__..__. CASING TYPE(S)
--�- -�-- --;-- --�— � �Steel � Plastic �Tile �Other
}1 mi
- —`- -�-- -�-- --1-- � _...�_. \� CASING(S)
� Dlamete� Depth t Set in oversize hole? Annular space initially grouted? .
S ,/� /_
�i mxe� �� - � in.irom S.� to_�L.2 ft. ❑ Yes �lo ❑ Yes ❑No ❑ Unknown
b
PROPERTV OWNER'S NAME '- in.from to R. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Pioperty owner's mailing adtlress if di8erent than well location address indlcaied above. in.from to fl. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
i83b2 Bear Pa�h Ttl SCREEWOPENHOLE !
�tt�T �/� r
Fden Pratt�� i�ti 5 5 347 Screen from �� ro J� ft Open Hole from ro R.
OBSTAUCTIONS
WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction
Well owners meilirg eAdress if dillerent than property owner's adtlress indicated above. TypB of ObSINCtions(DeSCribB) �""�"' ��G�- ) 7'" !�'GJ�/�/"�/C S
Obstructions removed? �Yes ❑ No Describe
PUMP
f ;
TYPe
GEOLOOICAL MATERIAL- COLOR� HARDNESS OF FROM TO � Removed �ot Present ❑ Other
FORMATION
N rat krawn,indicate estimated fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
d r i f t � 70 3�o Annular Space Exists
O Annular space grouted with tremie pipe
❑Casing PeAoration/Removal
in.from to R. ❑ PeAorated ❑ Removed
in.from to tt. ❑ Perforated ❑ Removed
Type of pertoralor
❑ otner
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Groutlng Material N��i ��"����,.L to��,L fl. yards �_ bags
from to ft. yards bags
from to ft. yards begs
from to__ ft. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property7 ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOH CERTIFICATION
This well or boring was sealed in eccordance wilh Minnesota Fules,Chapter 4725. The infortnation contained in this report is
true to Me best of my knowledge.
Don Stodoia We21 Dril2ing Co. , Znc. 27I72
Contractor Business Name License a Registrafion I':o.
- .--'"� 8-31-0 I
rized R resentative Signature �- Dare
.��tEl At1�UI130�!
H ������ Name ol Persan Sealing We0 a Bonng
LOI.'AL C.OP`Y
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