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Home My WebLink About8/16/18 Well and Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring3 5 1 WELL OR-BORING LOCATION Sealing No. H ' 15 4 County Nam, WELL AND BORING SEALING RECORD Minnesota Unique Well No. pMinnesota Statutes,Chapter 1031 or W a. a erinot es No. n) Township Ramei° Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed Orono 118 23 35 /§W''SE'ASW $/XV/e GPS LOCATION–decimal degrees(to four decimal places) / Depth at Time of Sealing flat ft. Original Depth ft. Latitude Longitude - .AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer WELL/BORING Measured Date Measuredy_ ❑Estimated 541 North Strom" Rai Orono 553972 Water-Supply Well ❑Env.Well Show exact location of well or boring Sketch map of well or.•r g rater-Supply Env.WellOther _ft. X1 below above land surface in section grid with"X:' location,showing prop= Temp. E ❑ lines,roads,and buildi •s N CASING TYPE(S) XSteel ❑Plastic ❑Tile ❑Other –4-4-----F------- /� Fi..... WELLHEAD COMPLETION W ET (J 11' Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset 'h Mile •ya"Nit I ❑Well Pit ❑Buried ❑ ell House - --T-- I ❑Well Pit yip ❑Other• ❑Buried I i Mile y—I ❑Other For multiple temporary environmental wells,provide additional location CASING(S) information,a site sketch,and geology on a separate page. Diameter / Depth i Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME V/,in.from V to/9� ft. ❑Yes XNo ❑Yes ❑No ❑Unknown Property owner Monicamai mg a rens l different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown SCREEN/OPEN HOLE WELL OWNER'S NAME/COMPANY NAME �r Screen from deg , to'82 /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 SINo Obstruction Type of Obstructions(Describe) _ Obstructions removed? ❑Yes ❑No Describe PUMP HARDNESS.OR GEOLOGICAL MATERIAL COLOR FORMATION FROM •TO Not Present ❑Present,Removed Prior to Sealing _ ❑Other If not known,indicate estimated formation log from nearby well or boring. Type dA,A yF b f,32 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE /� J6/1/No 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 No TN# GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) / / Grouting Materia 2 from_ . to / .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? ❑YesXNo 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 Driling Co.. Inc. 1691 Licensee Busine s Name License or Registration No. /� , 8 -30- I8 e Yepf :- Ive ignature Certified Rep.No. Date LOCAL COPY H \ NYill' t. v 3 5 915 4 Name of Person Sealing Well\o Wong HE-01434-16 ID#53159 tt 9/17R • WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes t NoWell and Boring H 359155 SealiCounty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Hennepin Minnesota Statutes,Chapter 1031 Low -series Noi Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed Orono 118 23 35 SW SE SW - z. - 1,f 11 '..1 2 . GPS LOCATION-decimal degrees(to four decimal places) Depth at Time of Sealing // ft. Original Depth 242 D ft. Latitude Longitude AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer r� North / ,..,. WELL/BORING k]Measured Date Measured - Z i /i' ❑Estimated 541 North Strom Rd, Orono 55391 /Water-Supply Well ❑Env.Well Show exact location of well or boring Sketch map of well or •ing in section grid with"X" location,showing pro. r, ❑Temp.Env.Well ❑Other /AU ft. below ❑above land surface lines,roads,and build) e- N CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other ---'-----1,----- --------- WELLHEAD COMPLETION Outside:�Pitless Adapter/Unit ❑At Grade Inside: Ill Basement Offset •--i--- -- W 'h Mileill i ❑Well Pit ❑Buried ❑Well House I p ❑Well Pit N El Other g ❑Buried I t Mile .�N ��,,� ❑Other For multiple temporary environmental wells,pro at& location CASING(S) information,a site sketch,and geology on a separ trISSe Diam�e1ter Depth Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME l in.from :� to /1 Lift. ❑Yes ❑No ❑Yes ❑No ❑Unknown Property owl nnerjs�mailing address if different than well location address indicated above in.from to C, ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown L" 'S. ...0Z SCREEN/OPEN HOLE f' Screen from to ft. Open Hole from /`- O`/ to 426 ft. WELL OWNER'S NAME/COMPANY NAME 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) l3 V< t 'Ai( '.' - •14 7U y/! Obstructions removed? V Yes ❑No Describe /, r'' i/t ti C -T PUMP GEOLOGICAL MATERIAL COLOR HARDNESS TION ❑NotPresent resenRemovedSealing ❑ FOORMRMATION FROM TO Pt, Prior to Other If not known,indicate estimated formation log from nearby well or boring. Type �/I l /2'7i if/) f-,-,.)/7 ,F 7- r} 3 c,' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal i7 1,-."Or -?7' y//I 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 pee° TN# GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Materiallf ii ,{; (fade, ,i,% from C% to t/ll 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 cileo 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. lit..)t`- Fa✓.w V'y 13 C 1-3,,,, ._/it- `01// / Don Stodola Well Milling Co., Inc. 1691 , • �/t /) i r�1 f i) curl ��y�� ! `/ '/ Licensee Business Na e License or Registration No. 17 T%'7Yl i> , -7.f! /wFi/ /�� ./ V . 0- dG - Ia itl,,(s 424) /ifhe."s#nta(ve SW:Tr-ore Certified Rep.No. Date LOCAL COPY " 359155 % - Name of Person Sealing Well or o HE-01434-16 ID#53159 t 7ertR