HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'I 281777
Sealing o
County Name
WELL AND BORING SEALING RECORD Minnesota Well NO.
Minnesota Statutes,Chapter 103 or W-series No.
afflWin (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 33 JW 9 Ju 09
•'OpS Latitude degrees minutes / }
_ seconds Depth Before Sealing F ♦ , ft. Original Depth tt.
LOCATION: Longitude degrees__ minutes_ seconds IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer ,,��// 51W M
FEnv.
ORING I�'�Qeasured ❑Estimated Date Measured
405 Old Crystal Bay Rd N ,-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or bin section grid with"X." location,showing prope Bore Hole ❑Other /27 ft. [below ❑above land surface
N lines,roa , d buildin CASING TYPE(S)
[Reel ❑Plastic !—'Tile ❑Other
--"--- -----'-- -- ELLHEAD COMPLETION
, T
W EI
Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
h Mil ess Adapter/Unit
❑Buried L1 Well Pit
dl
T -- - L1 Buried
S ❑Well Pit
❑ L1 Other
Other
PROPERTY OWNER'S NAME/COMPANY NAME ! CASING(S)
Smsu Diam e`0 0 t Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing a ress different t an we location address indicated above AV in.from V to/&7ft. ❑Yes Ao L]Yes ❑No E]Unknown
251 Starkey St in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
St Paul, Mht 55107
n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE I t , -
Well owner's mailing address if different than property owner's address indicated above Screen from /&7 to / A71 ft. Open Hole from to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
.r•
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS
ARDNE ONR FROM TO Obstructions removed? es E]No Describe FORMI
PUMP
If not known,indicate estimated formation log from nearby well or boring.
U � Type �p,jl- [1/�1.�
Removed F1 Not.PresInt ❑Other
OW
,M��ETTH�OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
levo Annular Space Exists L1 Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
FF in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 Ibs.)
Grouting Material m 0 to n It yards—/V 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 EX 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.
I
Don St"In Well Drilling Co., Inc• 16%
Licensee Business a License or Registration No.
erti dere ati a gna r Certified Rep.No. Date
LOCAL COPY H 28177
Name of Person Sealing Well or Boring
HE-01434-11 ICn 140-0423 2/08R