HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 13 30 0:]
WELL AND BORING SEALING RECORD Sealing H
County Name Minnesota
Unique No,
Minnesota Statutes.Chapter 1031 Or W-series No. -
Hennepin heave hiank if not known)
Township Name Township No. Range No. Section No. Fraction Ism.�Ig.) Date Sealed Date Well or Boring Constructed
rono 117 23 17 43-,013 S' ,J,c?,U qiZ
Numerical Street Address or Fire Number and City of Well or Boring Location > /
3590 Northern Ave, Orono 55391 Depth Before Sealing ft. Original Depth 30 ft.
Show exact location of well or boring Sketch map of well or boring IFER(S) STATIC WATER LEVEL
in section grid with"X' location, showing property Single Aquifer ❑ Multiaquifer
lines,roads,and buildings.
N WELUBORING Measured [:1 Estimated
-1 Water Supply Well ❑Monit.Well
' o ❑ Env.Bore Hole E:1 Other / it. ,TJ below El above land surface
W----- - -- - - --i- E -.•- CASING TYPE(S)
-�-- Steel E] Plastic E]Tile ❑ Other
CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
LLL S """"��J�� -- f'� ?
µ- f mile in.from` to +'/
r ft. ❑ Yes )(No ❑ Yes E]No E] Unknown
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
41
owner s mai mr 471 -9733
g a ds if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No E] Yes E] No ❑ Unknown
res
SCREEN/OPEN HOLE
Screen from 2L2 r to -30 ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME r '" X Rods/Drop Pipe p E] Check Valve(s) E3 Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if dif(er@ttpha r s address indicated above. Type of Obstructions(Describe)
JA�� r ORONO Obstructions removed? Yes [j No Describe
Ci,�Y V PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO El Removed Not Present El Other FORMATION
It 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:
No Annular Space Exits
-'� - ❑ Annular space grouted with tremie pipe
E:. ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) �j/
Grouting Material � ��� eo�l,) 'frrn /to�...L'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 OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boning 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 tlEll Drilling co. , Inc. 27172
Contractor Business Name License or Registration No.
A&thohz9d Representative signature Date
Lti
LOCAL COPY H
133007 Name of Person Sealing Well or Boring
HE-01434-03 2/97 R