Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 5 919 0 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Minnesotaeg <br /> County Name Unique Well No. <br /> HennepinMinnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave Clank IIr e known. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 10 SE 9S s' 9//?be - <br /> GPS LOCATION—decimal degrees(to four decimal places) .... • <br /> Depth at Time of Sealing /8ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WELL/ �,tBORING easured Date Measured Srtl bA)../ ❑Estimated <br /> 1525act oc onMkt ct oring Rd •' • <br /> ketch map of well or boring plater-Supply Well 11)Env.Well <br /> ow ex <br /> in section grid with"X." p �l location,showing property ❑Temp.Env.Well ❑Other 5 ft. "' below III above land surface <br /> N T( lines,roads,and buildings. CASING TYPE(S) ^^ <br /> t <br /> XSteel ❑Plastic ❑Tile ❑Other <br /> ---1-------------------f--- WELLHEAD COMPLETION <br /> w EI <br /> I_____ry____ ; _ outsidd Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mi- r [ [7,Well Pit ❑Buried ❑Well House <br /> -i- - 1 f _ <br /> ❑Well Pit <br /> s ❑Other <br /> ❑Buried <br /> I 1 Mile <br /> ❑Other <br /> For multiple temporary environmental wells,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter / <br /> Depth / Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME 4" in.from © to/85 ft. ❑Yes *No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown <br /> Enc. <br /> 4146 Shoreline Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Spring Park, MR 55384 SCREEN/OPEN HOLE <br /> �/ �i F <br /> WELL OWNER'S NAME/COMPANY NAME Screen from /B to 0 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above 14 Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe).A _/j ,. Pumfl <br /> Obstructions removed?XYes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present Present,Removed Prior to Sealing ❑Other <br /> Ifno known,indicate estimated formation log from nearby well or boring. Type <br /> A <br /> OJ METHOD USED TO SEAL AN LAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> No Annular Space Exists E Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removalsuing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> / r <br /> Grouting Material rom_S.1_ toff_ ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes)(No How many? _ <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION ////++++ <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> Don Stains Well Drilling-Co,. Inc.;. 1691 <br /> `_Licensee Business Name License or Registration No. <br /> • <br /> �/, . _ - Ar/47 <br /> 'ih 9=. - /• <br /> ,e'''''''''';re.re -ntafl ,�•'g .'ure Certified Rep.No. Date <br /> H 3 5 919 0 a'.: --t `.�.._.' <br /> LOCAL COPY Name of Person Sealing Well or B 'ng <br /> HE-01434-16 ID#53159 9/17R <br />