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