HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 241618
County Name
WELL AND BORING SEALING RECORD Minnesota SealingNo.
Well No.
IHennepin Minnesota Statutes,Chapter 1031
3.Ln e.i@pin or W-series No.(Leave Wank if not known)
Township Name Township No. Range No. Section No. Fraction(sm—Ig) Date Sealed Date Well or Boring Constructed
Orono 118N 23W 33 NE June 15, 2006 'iECEIVEc
GPS Latitude degrees minutes seconds Depth Before Sealing 1 5`, _ - ft. Original Depth JUL 2 4 f�
LOCATION: /006
Longitude degrees minutes seconds AQUIFER(S) STATIC WATER AVEL C
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer L /7-y n i.
2765 W Wayzata Blvd, Long Lake wELLBORING [ Measured ❑Estimat 0iluNO
cz Water Supply Well ❑Monit.Well lA
Show exact location of well or boring Sketch map of well or boring - 124
in section grid with"X" ', location,showing property ❑Env.Bore Hole ❑Other ft. ®below ❑above land surface
Na lines,roads,and buildings. CASING TYPE(S)
FvT Steel ❑Plastic ❑Tile ❑Other
W---r---,----r-'--,- E `°'j , 1- L' ` WELLHEAD COMPLETION
--- 1 i Outside: ❑Well House Inside: ❑Basement Offset
I f I t,ff,b ❑Pitless Adapter/Unit ,Well Pit
i -74
i..r ❑Well Pit ❑Buried
,,,J
) € ❑Buried
I
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
VCI Capital. Diameter Depth Set in oversize hole'? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above148
3 in.from 0 to ft. ❑Yes ;61,.No ❑Yes ❑No kl]Unknown
PO Boggy 375 'C
Long Lake, MN 55356 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes E No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
All
VCI Capital.
Well owners mailing address if different than property owner's address indicated above Screen from 1 48 to 1 S 2 ft. Open Hole from to ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill Olk No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring •
Type t }er
)(Removed ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
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 lbs.)
Grouting Material neat cement from 0 to 152 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 K No 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.
Stevens Drilling & PNvironm{_rttal Svc Inc 2255
Contractor Business Name License or Registration No.
(1,',.-r-j i:1' I ; ''''
r ,, / 1
p Authorized Representative Signature Date
LOCAL COPY
H 2 1618 Jason Ramthun
Name of Person Sealing Well or Boring