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HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 9 9 O 7 Sealin County Name WELL AND BORING SEALING RECORD Minneso aoUnique Well No. `j Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank if not known) Township r Township No. Range No. Section No. Fraction(sm.—a Ig.) Date Sealed Date Well or Boring Constructed Orono 117 - ig 1.04 NB Si AU& I I GPS Latitude degrees minutes seconds Depth Before Sealing •1 ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds AQUIFERS) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ��,,// .�,t�r.f tor'WELL/BORING �/�•Measured ❑Estimated Date Measured �.�+/.r 4/z` 840 Old Crystal Bay . . S, Orono Y 'Water-Supply Well ❑Monit.Well Show exact location of well or boring �`, R'ketch map of well oring ft, below in section grid with"X." 7 +M ation,showi ❑Env.Bore Hole ❑Other ❑above land surface es,roads,and buildings N }{ CASING TYPE(S) Steel E Plastic ❑Tile ❑Other .....1______—___$------i_-- 1 \ , WELLHEAD COMPLETION w E ___I___.__}___--4 ______I___ T Outside: ❑Well House ❑At Grade Inside: Basement Offset 1mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit ❑Buried S / ❑Well Pit T ( ❑Other —1 Mile----1 ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) tharlI Diameter . Depth t• • Set in oversize hole? Annular space initially grouted? Property owner's mailing address it different than well location address indicated above �� in.from to © ft. ❑Yes K"No ❑Yes ❑No ❑Unknown 15050 23rd Ave N in.from to ft. ❑Yes ❑No ❑Yes LI No ❑Unknown Plymouth, MN 55447 in.from to_ ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , Well owner's mailing address if different than property owner's address indicated above Screen from 9�. to �� , ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑DebrisQ(ill ❑No Obstruction Type of Obstructions(Describe) am, AJY I'��ApAhreg,. /� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? [ es ❑No Describe CIU�e� Allen 4e,�O FORMATION If not nonindicate estimated formation log from nearby well or boring. PUMP Type ❑Removed ( (lot Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: )11to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from ' to fti 30 Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement.94 lbs.,one bag ofbentonite.50 lbs.) • Grouting Material 7/'/ tt..CJ.1K—�! from GO to •T ft. yards 2 bags °'It from to ft. yards bags from to ft. yards bags OTHER WELLS AND BSiR J i REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING It Other unsealed and unused well fir bring o property? [_J Yes Xlo How many? LICENSED OR REGISTERED CalTR.'l3�CTO C RTIFICATION This well or boring was sealed in accdn i\l$Jrrnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. VV 711 Don Stable Wel + `libing Co. Inc. 1691 Licensee Busi - N. e License or Registration No. :;;.,:e 4?-- /— 1 1 Ce+ re•resentative','.� � a ure Certified Rep.No. Date 0.")......* LOCAL COPY H 299007 Name of Person Sealing Well or Boring HE-01434-12 IC#140-0423 9/09R