HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No.County Name2210133
WELL AND BORING SEALING RECORD Minnesota Unique Well No. H
HENNEPIN Minnesota Statutes,Chapter 1031 or W-series No.
lil*We blank If brown)
Township Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed
ORONO 117 23 02 "' SE' MN' Thursday,July 22..2004
GPS Latitude degrees minutes seconds
LOCATION: Depth Before Sealing 1131 ft. Original Depth taMi- record ff.
Longitude degrees minutes seconds AQUIFERS) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location i Single Aquifer 0 M4ltiaquifer
320 ROAD WELUBORING [ Measured 0 Estimated
lX Water Supply Well L]Monit.Well
Show exact location'of well or boring Sketch map of well or boring 70
in section grid with"X location,showing property 0 Env.Bore Hole El Other ft. [below .❑above land surface
N lines,roads,and buildings.
CASING TYPES)
:4:) -
I a ICH' Steel L]Plastic ❑Tile ❑Other
W I E
WELLHEAD COMPLETION
' i Outside: 0 Well House 'Inside:
-1--- ---l----�-- ❑Basement Offset
f I i f *M4' • dr h01ts6 i Pitless Adapter/Unit Well Pit
--I--" i i--.
' I ❑Well Pit ❑Buried
S
1.*--- a ❑BUried r
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
JAY;BEFL1AtAit4 Diameter Depth Set in oversize hole? Annular space initially'grouted?
P9 W
Property owner's mailing address if different than well location address indicated above �•:�ih.from__S to 161 ft. -
320 ORONO ORCHARD ROAD Yes C o • ❑Yes 0 No ❑Unknown
WAYZAtA,MN 55391 in.from to ft. 0 Yes
❑No ❑Yes 0 No ❑Unknown
in.from to ft. fl Yes ❑No ❑Yes; 0 •No, ❑Unknown
.
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
15. 1•01
Welt owner's mailing addres's if different than-progeny owner's address indicated above - Screen from - to •ft. Open Hole from - to . ' ft. '
SAS OBSTRUCT)ONS ..` ,
ERods&brop Pipe' '❑Check Valve(s) ❑Debris ❑,Fill •,❑ No,Obstruction ..
Rein lied 108',X 1.25":D1wp Pipe i A.Siih a T 1B'PnRmP---
Type of Obstructions(Describe)
HARDNESS OR
GEOLOGICAL MATERIAL COLOR FROM TO Obstructions removed? l3 res0 No Describe .
FORMATION
If not known,indicate estimated formation log from nearby well or bong PUMP _
00tyC3aYWi0iSand `�3rOVM.,. 0 T. 3: e� tutlp. .,
d(Removedi 0,Not Present .:- El,Other
METHOD USED T O SEAL;ANNULAfRSSPACEBE tWEEN 2 CASINGS,Pit CASING,MoiEICIRE}'IOlx:- ,
Sand( &ElaY Vaned 65 95 jjksfo Annylar Space Exists•.
p 0 Annular space grouted.wlth tremie pipe 'E] Casing RertoretiorVRemovals
(aay . 1410 ' in.from . to ft. 0 Perforated '.0 Removed
Sand&`Gravel M•
arie•
140 155 in,from to ft. El Perforated Removed
Sandy Cast WllWIG _ 155 160Typ'e o)perforator
.
Dred-07:13:404 ❑ Other
t78ptlt-4 x-t: 5a: GROUTING`MATERIAL(S) ; '((One bag of cefnent,94 ;one lbs bag of ben t elif a 50 lbs)
Grouting Material 1 from 6 to. -`8 5 - 0:0016'. '
SCWBn-1 5.4551yards bags
Static Wati�. 70' from 5.5 161 0 49q
t4 fti yards bags
from to ft. 8yards bags
' INFORMA'I1OIIfR U:;REPIA( aer4T'WBL 07.13.04 OTHER.WEL:LSANb BORINGS • .
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unseated and unused well or boring on property? g Yee .0 lip' How many2
well located it
100141 on rlOrttl'side of basement LICENSED OR REGISTERED CONTRACTOR CER1TflCAT10N
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
vAta depth Measured from grade1ewd true to the best of my knowledge.
rndh s leas not on site d! wen i ltl8i�the Wiaiar (763)493.3650 27800
Contractor Business Name License or Registration No.
vie( Cation of notification was Received fn nl mdh
July 2Z 2004
02 117 23 24 0002
Authorized Representative Signature Date
LOCAL COPY H 221083 .Name of Person Sealing Well or Boring