Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSeal411629 <br />emepin WELL AND BORING SEALING RECORD Minnte9otaoUnique Well No. , <br />Minnesota Statutes, chapter 1031 or W-series No. <br />(tame dank a rwt kmxn) <br />TmqkDame jTownl"o. R2ge No, Se6lon No. acligt (srrNV Ig.) Date Sealed 8/13/2024 Date Well or Boring ConstgMA/1979 <br />'/ ,/4 <br />GPS LOCATIC 94fty2Idegrees (to four decimal pl-a§l639947 125 125 <br />Latitude Longitude Depth at Time of Sealing ft. Original Depth ft. <br />QUIFER(S) STATIC WATER LEVEL <br />"3rW ArpH "4€MsLoARE OR (fit 84Boring location Single Aquifer ❑ Multiaquifer 8/13/24 <br />WELL/BORING Measured Date Measured ❑Estimated <br />Water -Supply Well El Env. Well 73 <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X" location, showing property ❑Temp, Boring El Other ft. 1G�1 below ❑above land surface <br />N lines, roads, and buildings. CASING TYPE(S) <br />w <br />t <br />E <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />f WELLHEAD COMPLETION <br />T <br />Outside:x Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset <br />'h Mile ❑ Well Pit ❑ Buried ElWell House <br />)> ❑ Other ❑ Well Pit <br />s a ❑ Buried <br />i1 Mile ❑ Other <br />For temporary borings, provide additional location ,'' 1eA i CASING(S) <br />information, a site sketch, and geology on a separate page. Diameter 0 DepT21 `� Set in oversize hole? Annular space initially <br />grouted? <br />Yd55FF nW I f IVAME/COMPANY NAME in. from to ft. P Yes ❑ No ❑ Yes ❑ No yJ Unknown <br />Pro er owner's mailing address if different than well location address indicated above in. from to ft. [I Yes ❑ No ❑ Yes ❑ No f 1❑ Unknown <br />215 forth Arm Lane <br />Orono Mn 55364 in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN fjQL1E 125 <br />18FhIdW&RCS" FiS9yPANY NAME Screen from to ft. Open Hole from to ft. <br />OBSTRUCTIONS <br />Well owner's mailing address if different than property owner's address indicated above ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill] No Obstruction <br />2536 -18th Ave S <br />Minneapolis, MN 55404 Type of Obstructions (Describe) <br />Obstructions removed? ❑ Yes ❑ No Describe <br />PUMP XXXX <br />GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br />FORMATION ❑ Not Present Present, Removed Prior to Sealing ❑ Other <br />Subme sible <br />If not known, indicate estimated formation log from nearby well or boring. Type <br />JaETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />Clay Yellow 72� .9--No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal <br />sing Diameter <br />Clay B Ue 19 00 in. from to ft. ❑ Perforated ❑ Removed <br />n. from to ft. ❑ Perforated ❑ Removed <br />Sand ruw[I 112 125 Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes ❑ No TN# <br />GROUTING MATERIAL(S) <br />_ I Neat Cement 0 125 10 <br />Grouting Material from to ft. yards bags <br />from to ft, yards bags <br />from to ft. yards bags <br />KOM moo ant 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 />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 />ELEVATION: 968FT is true to the best of my knowledge. <br />E.H. Renner & Sons, Inc. 1431 <br />Licensee B in s Name License or Registration No. <br />tj Iry / hj8/19/2024 <br />GEOLOGY FROM ORIGINAL WELL RECORD <br />Certified Re resentative Signature Certified Rep. No, Date <br />ED RENNFIR / NICK ANDERSON <br />LOCAL COPY H 411629 Name of Person Sealing Well or Boring <br />HE-01434-17 ID# 53159 11/19R <br />