HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OP HEALTH Minnesota Well and Boring 1 r"'��� � („'
> WELL OR BORING LOCATION Sealing No. H .,J �,j,,,I `)
^ County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Cha ter 1037 or W-series No.
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Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
Orono lI7 2 OS r•NF'� ,� � ` �('+,J (
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GPS Latitude degrees minutes _ seconds Depth Betore Sealing� ft. Original Depth __ fl.
�'t LOCATION: Longitude__ degrees minutes seconds �FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ��ngle Aquiter ❑Multiaquifer �} � /���
495 thcfarr1 R�, CIrOI� y�✓[€LUBORING �Measured ❑Estimated Date Measured.�7��.� �X!
�7 Water-Supply Well ����MoniL Well �
Show exact location of well or boring Sketch map of well or b ring i �/
- in section grid with"X" location,showing prope ty ��Env.Bore Hole � �Other____ �r _ft. �below �]above land surface
N lines,roads,and buildin s`` CASING TYPE(S)
�� --'--- —— `- ---'— . ��.
� ; i , f �� 1 steei ❑Piast�o Cl T�ie -I o�ne� —___ _ _
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� "''- � ' ' -�' '''-- � WELLHEAD COMPLETION
. W ; ; ; ; ET �
_� ;_ _ _�___ r }, Outside: ❑Well House []At Grade Inside: ❑Basement Offset �
'h Miie ' ❑Buried ❑Well Pit `
� . :\ �Pitless Adapter/Unit �
❑Buried :
S /^�, ❑Well Pit
❑Other
�1 Mile� ' ❑Othef
PR E+RTY OWP�NER'S MPANY NAME CASING(S)
�`��'41�`��"�� Diam ter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different ihan well location address indicated above �f
r '
�_in.trom Q to� � ft. n Yes �No !.]Yes [_j No ❑Unknown _
7407 Tdayzata BZvd _ °
.7t Wli�$ �$��� M�3 55426 in.fram to ft. �]Yes '���_�No ��LJ Yes L�No �Unknown
__in.trom to ft. ❑Yes ❑No [.J Yes L I No j]Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � �
Well owner's mailing address if different than property owner's address indicated above Screen from_�� to f�� ft. Open Hole from to _ft.
�-�, �� �. � t_='1� �t��t�- "' i�)�...i � OBSTRUCTIONS
�Rods/Drop Pipe �]Check Valve(s) �]Debris [�Fill [�No Obstruction
3 Type of Obstructians(Describe), /n/N�� /=� 4' �U/1')(�
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GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. -� ;
l� r TYP� ��JQ� M - —
? , �--
i - E� � � �`-'�� �,Removed �;Not Present r]Other ... __
;��J METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
_ in.from_ _ to _ft. ❑Perforated [i Removed
in.from,__ to ft. ❑Perforated ❑Removed
Type of Pertorator_
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
� �a+ � i
? GroutingMaterial/V�I�rr �L��+� from U to�� ft. yards ��- bags
from to ft. yards _ bags
from to ft. yardg _ bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIPFICULTIES IN SEALING Other unsealed and unused well or boring on property? I 1 Yes �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.
Ibn Stalola ��ell Dr�.11in� Co.� Inc. 1691 _
Licensee Bus�nes Nr+e { ' /. � License or Registration No.
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/ / `/
_C,SRR'i Representative Signatuie - � Certified Rep.No. Date
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���� " 3 0 9 6 � 5 ,.__r___. _�-� � _. _, ..v;
-_ - - - � -
� Name ol Person Sealing Well or Boring �
HE-01434-13 IC#140-0423 . � 5n2R
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