HomeMy WebLinkAbout05/22/19 Well and Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 5 8 2 4
County Name WELL AND BORING SEALING RECORD M
Sea
oUnique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
(Leave dank if not known)
TowNR11011 Township No. Range No. Section No. Fraction(sm.-Ig.) Date Sealed Date Well or Boring Constructed
Orono IIT 23 01 Ili Sa ii 6./2 /19
GPS LOCATION-decimal degrees(to four decimal places) 0
Depth at Time of Sealing /04 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location yXSingle Aquifer ❑Multiaquifer
'WELL/BORING X Measured Date Measuredliene_2141eL Estimated
�ater-Supply Well ❑Env.Well a
Show exact location of well or boring Sketch map of well or boring U Env.Well Other /� ft. X below above land surface
in section grid with"X." location,showing property Temp. ❑ (fi ❑
N lines,roads,and build igs`. CASING TYPE(S)
y (f[
_} *eel Plastic ❑Tile ❑Other
J WELLHEAD COMPLETION
E p Outslde:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'IIA Mile • ❑Well Pit ❑Buried ❑Well House
d ❑Other LI ❑Well Pit
s }
❑Buried
1 Mile h
❑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 fn.fromte/� to ft. ❑Yes No ❑Yes ❑No ❑Unknown
p i
Prone s mai i rens if different than well location address indicated above in.from r - to ft. ❑Yes ,❑',No ❑Yes ❑No ❑Unknown
2435 %mutts lilvd is in.from to ft. 111Yes ❑No ❑Yes ❑No ❑Unknown
tang law, IN 55356 SCREEN/OPEN HOLE
�qf
WELL OWNER'S NAME/COMPANY NAME a
Screen from Jaz. r to /cas 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) fN . T Sue //rir
Obstructions removed? "Q�Yes ❑No Describe
PUMP �'i�
HARDNESS OR
GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Not Present resent,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type 5 V L3 Ai rn�
d
/( /®L METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
�.J ) Aa o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
ing 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 beg of cement- 4 lbs.,one beg of bentonite a 50 lbs.)
Grouting Material omL toi_ot.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 XNo How many? n.
LICENSED OR REGISTERED CONTRACTORCERTIFICATION. t" ,':, i .,.
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4721'he informacontained in this report
,is true to the best of my knowledge.
Don Stgdoia Well Drilling Co;. Inc. 1691
Licensee Business Name License or Registration No.
j - d 1
Certified Rep.No. Date
LOCAL COPY " 3 6 5 8 2 4 .,-, .
Name of Person Sealing Well or Bonin
HE-01434-16 ID#53159 ymp
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