HomeMy WebLinkAboutWell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO.
County Name Hennepin (leave blank if not known) 2 1 5 1 6
Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Data sealed
N E k k of 4
or or ft.
Orono 118N S 23W W 33 SE NE SW 126 07/10/92
Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known)
Intersection 10 Cable tool 40 Reverse 70 Driven 10(]Dug
245 North Old Crystal Bay Road Orono 20 Hollow Rod 50 Air BD Bored 110
Show exact location of well 30 Rotary 60 Jetted 90 Power Auger
(in section grid with 'X') 55356
Sketch map of well location
N 6. OBSTRUCTIONS
Well obstructed 0 Yes ® No
- u - - - -- Obstructions removed(]Yes [3 No If obstructions cannot be
removed, contact MON
W _ _ _ . _I- . _ E before sealing.
T 7. USE
y.R. 'AA DO-5 c 40 Monitoring 60 heat Loup
_ 1 20 Irrigation 50 Public 90 Industry
30 Test Well 60 Municipal 100 Commercial
1
La--------- 70 Air Conditioning 110
2. PROPERTY OWNER'S NAME Mailing Address if different than 8. CASINGS)
property address indicated above 10 Black 4n Threaded 70
Tom Aldrich 2W Gal v. U Welded
3r3 Plastic 60 Stainless Steel
HARDNESS OF 2
3. FORMATION LOG COLOR FORMATION FROM TO in. to ft.
If not known, indicate formation log from new well or nearby well, in. to ft.
9. SCREEN
®Screened well from_ ft. to ft.
(I` known)
0 Open Hole from_ ft. to s ft.
10. STATIC WATER LEVEL
4 7 ft.E:] below 0 above
land surface Date Measured 07/10/92
11. WELLHEAD COMPLETION
10 Pitless Adapter 40 Found Buried
2® Basement offset
30 Well Pit
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
12. GROUTING INFORMATION
I®Neat Cement 20 Bentonite 30
.•ro.,. »�.a�iei 21e bati from to-T-7�tt. cu. yds
13. NEAREST SOURCES OF CONTAMINATION
feet direction type
Well disinfected before sealing? ® Yes
14. PUMP ®Removed 0 Not Present
Type: 10 Submersible 30 L.S. Turbine 50 Reciprocating
20 Jet 40 Centrifugal 6[]
15. EXISTING WELLS (Please sketch locations of abandoned and
active wells in remarks section or on back.)
Other unused well(s) on property? 0 Yes ® No
Abandoned: 0 Permanent 0 Temporary 0 Not sealed
17. WATER WELL CONTRACTORS CERTIFICATION
This well was sealed under my jurisdiction and this report
is true to the best of my knowledge and belief.
Stevens Well Drilling Co. , Inc. 27194
624U'11'1gnway'IT West License No.
Address Maple Pla , MN 55359
Signed 1 (At... (._._.— oate 07/14/92
Joe Stevens & Jeff DaCe 07707-9-7
OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller
IMBCiRTAET: FILE KITH DEED