HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH No. and Boring H 244420
Sealing
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
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Township NemB A Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
Orono 118 23 35 41-OiO2 '" ' 73 >-F Q elf.
GPS Latitude degrees minutes '
LOCATION: Depth Before Sealing /,30 ft. Original Depth ft.
Longitude degrees minutes seconds MOWER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Aquifer 0 Multiaquifer
WELL/BORING Cbtheasured 0 Estimated
• !, 7. ¢ • .• Nater Supply Well ❑Montt.Wel
ng
m section grid with'X" location,showing 0 Env.Bore Hole 0 Other ft. R/below 0 above land surface
N }� Iphes 'a • CASING TYPE(S)
i 1 jSteel 0 Plastic 0 Tile 0 Other
W E WELLHEAD COMPLETION
1 I 1 Outside: ElWell House Inside: Basement Offset
1 1 1 I Uwe -.-t.:-.1 Pitless Adapter/Unit 0 Well Pit
1 0 Wet Pit 0 Buried
S
4 r mrr I ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameter
. DepthSet in oversize hole? Annular space initially grouted?
PrXdie� �affitd(erent5v igatine1in.from )
to /2 ft. ❑Yes 'lo ❑Yes 0 No 0 Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No 0 Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No 0 Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
r I
Well owners mailing address if different than properly owners address indicated above Screen from /26p to /36 ft: Open Hole from to ft.
OBSTRUCTIONS
X Rods/Drop Pipe ❑Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions(Describe) Wen") frau6 j a i 4r1.1</;'S
ESS OR
GEOLOGICAL MATERIAL COLOR �FORNMp FROM TO Obstructions removed? NYes 0 No Describe
If not known,indicate estimated formelon log from nearby well or boring PUMP �°'�,
�
'` tr_�� Type ST Pi w m D
`�-' r V -� VRemoved
0 Not Present 0 Other
/ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOREHOLE:
*No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal
in.from to ft. 0 Perforated 0 Removed
in.from to ft. ❑ Perforated 0 Removed
•
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one beg of bentonite=Me Ars.) - .. `?`,
Grouting Material.4/4/49-‘74_!i"`�C/T from_to )p ft. yards 3 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? 0 Yes X No How many?
UCENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordarde w lth'Minnesot Ruled,Chapter 4725.Tim informaton "contained In this report is
true to the best of my knowledge.
+ .. s 'N—ld 0 Drilling Co.,
orb T s 27172
Corgi BuiassmRegis
tation No.
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t1v Dare
LOCAL COPY H 244420 ''s,s. i f.' ,,nm-'
Name of Person Sealing Well or Boring