HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO.
(leave blank if not known)
County Name Hennepin
Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sea ed
N E k 4of k r f
Orono 117 or 23 yr 04 NE SE NW 3j L_f ft. -? d +6-1
Numerical Street Address and City of Well Location or Distance from Road 5. IL ING METHOD (if known)
intersection 1 Cable tool 1[3 Reverse 7[]Driven 100 Dug
335 Old Crystal Bay Road Orono, Mn. . 20 Hollow Rod 50 Air BD Bored 110
3D Rotary 60 Jetted 5Q Power Auger
Show exact location of well
(in section grid with 'X') Sketch map of well location
6. OBSTRUCTIONS
M
Well obstructed Yes No
� Obstructions rNoved es 0 No If obstructions cannot be
i removed, contact MON
M - ' - -J( -I- ` - E I , )( l'4 before staling.
, I � ► way
T cV'f' (n 7.os(i
'"'-- '' y mi -V 1 Domestic 40 Monitoring B0 Heat Loop
L 20 Irrigation 5[J Public 90 Industry
S A 30 Test Well 60 Municipal HIDCommercial
0---1 ori La--4 70 Air Conditioning 110
2. PROPERTY OWNER'S NAME Mailing Address if different than R. CASiNG(S)
property address indicated above 10 Black Threaded 70
Mimi Ryerse Cleary Construction Galv. 50 Welded
P.O. BOX 120 Long Lake, MN. 30 Plastic 60 Stainless Steel
HARDNESS OF ) 80
55356 e...4 ,n. to ft.
3. FORMATION LOG COLOR FORMATION FROM TO
If not known, indicate formation log from new well or nearby well. in. to ft.
Drift 0 84' 9. SCREEN
®Screened well from 8 0 ft. to 84 ft.
(If known)
0 Open Hole from ft. to_ ft.
10. STATIC WATER LEVE
ft, below 0 above 7 / /
land u ce Date Measured / / ( 41 I
11. WELLHEAD COMPLETION ((( ff
10 Pltless Adapter 4:3 Found Buried
20 Basement offset 4]
Well Pit
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED. ETC.
12. G_ RO(1TING INFORMATION
J�`p'(�Neat Cement (3 Bentonite 3[(
Grout 2" Well Approx. 84' Deep Grout material fromto O ft. cu. yds
2 Bags Cement _ _
4 Lbs. Bentonite 13. NEAREST SOURCES OF CONTAMINATION
2 Men, Labor, Rig and Cement Grout Pump ^ feet direction type
Well disinfected before sealing? 0 Yes
14. PUMP 0 Removed 'Not Present
I CITy OF Type: 10 Submersible 30 L.S. Turbine Reciprocating
ORONo 20 Jet Centrifugal 60
0 f ri 15. EXISTING WELLS (Please sketch locations of abandoned and
active wells in remarks sec o or on back.)
Other unused weil(s) on property? D Yes No
Abandoned: 0 Permanent 0 Temporary 0 i s &led
A U 2 2 17. WATER WELL CONTRACTORS CERTIFICATION
1991 This well was sealed under my Jurisdiction and this report
1 is true to the best of my knowledge and belief.
DON STODOLA WELT, DRILLING CO. , INC.
Licensee Business Name License No.2 7 1 72
Address 15306 Hwy. 7 Minnetonka, Mn. 55345
SignedDate 7-8-91
7 Mark Sto ola Date 7-8-91
OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller
IMPORTANT: PIM WITH MOLD
.