HomeMy WebLinkAboutWell & Boring Construction Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 362 /I Q
County Name o.
WELL AND BORING SEALING RECORD Sealing Na Unique Well No. 9`t V
Minnesota Statutes,Chapter 1031 or W-series No.
(Leave dank if not known)
Towns Ip�a e g Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 20 1 N$ i 3-e-/1 i ‘,,0
GPS LOCATION—decimal degrees(to four decimal places) g
Depth at Time of Sealing `2S ft. Original Depth �2 ft.
Latitude Longitude
AOUIj;ER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Ingle Aquifer ❑Multiaquifer 1
WELL/BORING M .7
easured Date Measured „3—.7-,r7 ❑Estimated
2455 Meelyunatt Rat Aram 55351 QWater-Supply Well ❑Env.Well
Show exact location oT well or boring Sketch map of well or boring
in section grid with"X." location,showing property ❑Temp.Env.Well ❑Other 8 ft. 2elow ❑above land surface
�y,/Y� 1es,roads,and buildings.
N CASING TYPE(S)
___L.. l r'�I�",
IAV 4 feel ❑Plastic ❑,Tile ❑Other
-----' _ WELLHEAD COMPLETION
Outside:,,W'Pitless Adapter/Unit ❑At Grade Inside: El Basement Offset
...2 g
%Mile ❑Well Pit ❑Buried ❑Well House
--- 1 0 Other ❑Well Pit
s ❑Buried
F---1 Mile 1
❑Other
For multiple temporary environmental wells,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. Diamet r Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME in.from to ❑Yes ❑Yes "o ❑Unknown
Proper owns ss if different than well location address indicated above in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEN/OPEN HOLE ,�+
WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from ��to ��7 ft.
OBSTRUCTIONS�
' Well owner's mailing address if different than property owner's address indicated above Imo'rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) ��� IV)11
Obstructions removed? ikoees ❑No Describe
PUMP
GEOLOGICAL MATERIAL 1 COLOR I HARDNESS OR I FROM ITO
FORMATION ❑Not Presentesent,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type 4-5.1V,
Of F T 1...) /�.'t trj ME OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
.S/f/ TvA/e" .j�357 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? ❑Yeso TN#_
GROUTING MATERIAL(S) (One bag of cement.94 lbs.,one bag of bentonite=50 lbs.)
Grouting Materialo" from a to.Z e 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? ❑Yeslo How many?
1 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 Steiila Well Drilling Col, Inc. 1691
Licensee Business Name License or Registration No.
V
e ed -present.,".i. —' Certified Rep.No. nate.
'1—CLIAsk
LOCAL COPY H ('r \—�•.
3 V L J 4 V Name of Person Sealing Well or Boring
HE-01434-16 ID#53159 9/17R