Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 3 8 5 5 6 0 <br /> WELL <br /> OR BORING LOCATION WELL AND BORING SEALING RECORDCName Minnesota No. <br /> Well No. H ) <br /> Minnesota Statutes,chapter 1031 or W-series No. y--.3 -..-,, <br /> -.3 3 . G <br /> ....... <br /> A Bane jr1L1 <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> urono 117 i., ub S2 S'It ti 6 . , ' c2r5aZ / 1/ - /o2 - :a 13 <br /> I'I GPS LOCATION-decimal degrees(to four decimal places) .. <br /> Depth at Time of Sealing /,.."✓ ft. Original Depth l frr"' 9 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 /> ELL/BORING ❑Measured Date Measured ❑Estimated <br /> U'+Li 4,axaview Parkway, Orono Water-Supply Well E Well <br /> Show exact location of well or boring j 5 3k,4 Sketch map of well or boring Temp.Boring section grid with"X." location,showing property ❑other ft. ❑below ❑above land surface <br /> lines,roads,and buildings. 1, <br /> N CASING TYPE(S) • <br /> - -----i <br /> ❑Steel ›i Plastic ❑Tile ❑Other <br /> :--;--'-- I <br /> - WELLHEAD COMPLETION ' <br /> W 1 ET <br /> Outside:s Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> ------ h Mile ❑Well Pit ❑Buried Well House <br /> u' ❑ <br /> ❑Well Pit <br /> --- ----1- 1 -,,,....4). 1 - ❑Other <br /> s 1 <br /> ❑Buried <br /> 1-1 Mile I _, <br /> t ❑Other <br /> For temporary borings,provide additional lodat n CASING(S) <br /> information,a site sketch,and geology on a se arate page. <br /> Diamet r /++ Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from (1) to ./.:"f..//2ft. ❑Yes /1 No ❑Yes ANo ❑Unknown <br /> 1 P L Landscape <br /> Property owner's mailing address if different than well location address indicated above Li ❑ ❑ ❑ ❑Unknown <br /> in.from to ft. Yes No Yes No <br /> P.O. DO Y 1716 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> i urnvii1e, MA 55300 SCREEWOPENHOL7E <br /> / 7Q <br /> WELL OWNER'S NAME/COMPANY NAME Screen from /c.7{e) to/u ! ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above XRods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) 7.`.r- _j <br /> Obstructions removed? `hie Yes ❑No Describe <br /> PUMP f^ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present IA`Pr�esent,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type ' sem. ` ,--6-^•-C-,-. -�.• <br /> i (9 J,6 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE 1 <br /> sem✓ o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> / rng 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 Flo TN# - <br /> GROUTING MATERIAL(S) T� <br /> , <br /> Grouting Material/� 1-'� '.r,J "'`f{oj 1 �m �/ to . . 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 lY Jo 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 /> uon 6todola well Drilling Co. , Inc. 16 -1 <br /> Licensee Business Name License or Registration No. <br /> C- :.Re. -f e Signatur- ''"*- Certified Rep.No. Date <br /> LOCAL COPY H 3 6 5 5 6 0 \, `"` 1/41:::3 <br /> ���' <br /> Name of Person Sealing Well or Boring-Tr.; <br /> HE-01434-17 ID#53159 ' . S# 11nSR <br />