HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTHMinnesota Well and Boring r 163486
WELL OR BORING LOCATION ling No.
SeaH
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. r - — -
Hennepin Minnesota Statutes, Chapter 1031 or W-series No.
(Leave dank If not known)
Township Name Township No. 'Range No Section No. Fraction Ism.-I Ig.) Date Sealed Date Well or Boring Constructed
Orono 118 23 35 ti 7/19/00 NA
Numerical Street Address or Fire Number and City of Well or Boring Location Ge` l #
Depth Before Sealing1 12 h. Original Depth eke
825 Old Long Lake Road, Wayzata g '� �b �\�
Show exact location of well or boring Sketch map of well or boring AA�OUIFER(S) STATIC WATER LEVEL ��
in section grid with"X". location, showing property `-T Single Aquifer ❑ Multiaquder
lines,roads,and buildings �y`(
N WELUBORING (^ Measured ❑ Estimated ' �V
• (i r(ii 1 i f'�Water Supply Well ❑Monit.Well �73 N
r , , ,
L_,:t
`❑f'Env.Bore Hole ❑Other f h below ❑ above land surface
W r--,----, E " CASING TYPE(S)
i ( Steel ❑ Plastic ❑Tile ❑Other _
I I I I }ft mile
1__- CASING(S)
'�'"'�� Diameter Depth Set in oversize hole? Annular space initially grouted?
It, r mire, 4
r' 2 in.from 0 to 108 tt. ❑ Yes 9 No ❑ Yes ❑No 171` Unknown
PROPERTY OWNER'S NAME in.from . to ft. ❑ Yes ❑No ❑ Yes ❑ No yl Unknown
Unknown
Bruce Dayton
Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
C/8 Larry Carlson SCREEN/OPEN HOLE
965 Old Long Lake Road Screen from 101 to 112 h. Open Hole from to ft.
Wayzata, MN 55391 OBSTRUCTIONS
WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill 'Cl No Obstruction
Well owner's mailing address if different than property owner's address indicated above Type of Obstructions(Describe) `�`
Obstructions removed? ❑ Yes ❑ No Describe
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed El Not Present CI Other
• FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
`yl 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 Matenal Neat Cement from 0 to 112 ft. yards 7 e 5 bags
from to ft. yards bags
from to ft. yards bags
. from to— ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes `r✓t'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.
;t:svens Drilling & Env. Services. Inc. 86654
Contractor Business Name License or Registration No.
, 7/21/00
Authorized Representative Signature Date
Richard Stevens
.'KCAL Co i- H 163486 Name of Person Sealing Well or Boring