Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnes�ota Well and Boring ir �(,���� � <br /> WELL AND BORING SEALING RECORD Mennlesota Unique Weil No. I H `� <br /> Gounry Name -- <br /> ^^ Minnesota StaNtes.Chap�ei 1031 or W-series No. � � <br /> xeiJ)ie ��"i h.eave aenk tt na known) <br /> Township Name Township No. Range No Secuon No. Fract�on�sm.-s Ig) Date Sealed Date Well or Borirg Construaetl <br /> Orono l 17 23 1 T �• �� /t� !�r�..� r�J' <br /> Numencal Street Address w Flre Number and Ciry of Well or Bonng Location <br /> / / f � <br /> � /L� ShadyMood Rd• ��Q��) ��• Depth Before Seahng ��lC _N. Original Depth . f/l ri <br /> Show exact locatwn of v.•ell or bormg Sketch map of uCell qvp nng OUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X'. . .. . IocaLon, showing)¢roperty Single Aywter ❑ Mulhaquder <br /> lines,roads,and buildings. <br /> N �, . WELL/BORING �Measured ❑ Estimated <br /> (�Water Supply Well ❑Monit.Well ! <br /> �❑~Ern.Bo�e Hole ❑Other ��_ft. �below ❑ above land suAace <br /> T� <br /> W -�- -�-- -;— --;-- E . ... CASING TVPE(S) <br /> � � � � , <br /> � � � <br /> � � � <br /> -�-- -�-- -i-- --i-- � � . � �Steel � Plastic �Tile � Other <br /> Yzmila �._._—n.+ - — <br /> � � � + ; ..__. ( ) <br /> -�-- -i-- -� - --i— � � CASING S <br /> � Diamete�r Depth � Set in oversize hole7 Annular space initially grouted? <br /> S i t'l m.trom� to� fl. ❑ �es �No ❑ Yes ❑No ❑ Unknown <br /> �I mHe � <br /> PROPERTY OWNEF'S NAME � . in.from to fl. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown <br /> Property owner's mailmg aAdress B�itterem than well locauon address ind�cated above. m.hom to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> 9J6�41�.'�'OGS� SCREEWOPENHOLE <br /> � /� ! <br /> Screen from_���to__1_1',G ft. Open Hole from ro ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME [�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailin atldress if tliHereN than ro e owner's address indicated above. �Jr.�) � <br /> 9 P P M Type of Obstructions(Describe)���},(��y����f f �'�/`�� g- ����l�l�%f���� <br /> arH�b 82 tte=•/RQ��� Obstructions removed? es ❑ No Describe <br /> /0 1 J <br /> FAX 952-475-801� PUMP N <br /> TyPe "`(�t-'-�` f-~�a!r"a��t f` <br /> GEOLOGICAL MATEHIAL COLOR MARDNESS OF FROM TO �emoved ❑ Not Present ❑ Other <br /> �. FORMATION <br /> � If not known,indicate estimated tortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � y �o Annular Space Exists <br /> ' f �,�'' ❑Annular space grouted with tremie pipe <br /> , . <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from �o n. ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) �One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> GroutingMatenal r+l�',!-�/ , '� �irom �` ro � �= ft. f <br /> yards � bags <br /> from to ft. yards bags <br /> from to R. yards bags <br /> irom to_ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> LICENSED OR REGISTEREO CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> I�ON STODOLA 6�ELL DRILLIN�' CCt. , IIV�. 27'172 <br /> Contiactor Business Name License or Registretion hJo. <br /> s <br /> .. - ��F _- .�� . ' = . a <br /> x• <br /> AYfuthopi"ed Representative Signature Date <br /> - . . . d_ _ , �`r/ <br /> H ��J ��� Name ol Person Sealing Well or Bonng <br /> LOCAL COPY Z <br />