HomeMy WebLinkAboutWell and Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MinnesotaSealieg NWell and 9gring H 3 9 1.
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. 5 5 9
Minnesota Statutes,Chapter 1031 orB W s eries No.
Township N men Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 17 SiE gE §67 8/29 //6
GPS LOCATION—decimal degrees(to four decimal places) #
Latitude Longitude Depth at Time of Sealing 2# ft. Original Depth ft.
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number andmeCity of Well or Boring Location Single Aquifer ❑Multiaquifer i�
3635 Togo Rd, Orono 55391 ELL/BORING INtMeasured Date Measured 514/71C /A ❑Estimated
Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring 1
in section grid with"X." location,showing property ❑Temp.Env.Well ❑Other /, ft. Xbelow ❑above land surface
Nnes,gand ings. CASING TYPE(S)
❑Steel ❑Plastic ❑Tile XOther - • a I,
---'----- ---`-----f--- T WELLHEAD COMPLETION
w EI
________________r Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'h Mile 1....... ..=.),i
[1]Well Pit ❑Buried ❑Well House
-------- ---- ---- -- 1
❑Well Pit
s ❑Other
❑Buried
I1 Mile-----1 !
yrOther
For multiple temporary environmental wens,pro ide 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 din.from_aL to_al_1 ft. ❑Yes >INo ❑Yes ❑No ❑Unknown
!Vivid &eablfb
Property owner's mailing address/ if different than well location address indicated above in.from to ft. El Yes ❑No ❑Yes ❑No ❑Unknown
227Ridge in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Golden Valley, TIN 55422 SCREEN/OPEN HOLE
WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)..4hpA.€ den -' } F tt/R<✓�
Obstructions removed? .Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present XPresent,Removed Prior to Sealing ❑Other
If not sown,indicate estimated formation log from nearby well or boring. Type
Al I.J t METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CAS GS,OR CASING AND BORE HOLE
���LL..JJJ XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
Casing 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 o TN#
GROUTING MATERIAL(S) (One bag of cement=9 lbs.,one bag of bentonite=50 lbs.)
Grouting Materia 4 7 OS06//jr from_ to ft. yards_3r,_ 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 XNo 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 Stodola Well Drilling Co,.. Inc. 1691
Licensee Business Name • License or Registration No.
_ 8- 30_ / ya
di=- -e.� .five Sig ature Certified Rep.No. Date
LOCAL COPY " 3 5 9 .15 9 Name of Person Sealing Well or §ring ik ` ANN
�'sY-NJ
HE-01434-16 ID#53159 I91178