HomeMy WebLinkAbout05/29/19 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 5 8 3 2
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No.
County Name Minnesota Unique Well No.
p
/� Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin i (Leave blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date SealedDate Well or Boring Constructed
Orono 117 23 02 NB SE NW s/2 S /1?
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing / ft. Original Depth ft.
Latitude Longitude
ADUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
Measured Date Measured 5�i/) Mr'❑Estimated
1250 Woodhill AVe, Orono WE LJBORING
Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well orb ring LQJ
in section grid with"X:' loco io sh g prop Temp.Env.Well ❑Other ft. below ❑above land surface
N Ines,rroas
a buddl s. CASING TYPE(S)
t IySteel ❑Plastic ❑Tile ❑Other
WELLHEAD COMPLETION
W ET
t\�
_ _ __ I ` Outside: hitless Adapter/Unit ❑At Grade Inside: [11 Basement Offset
'h Mile ❑Well Pit ❑Buried ❑Well House
r 1 ❑Other ❑Well Pit
s ❑Buried
1 Mile {
1 ❑Other
For multiple temporary environmental wel , ro de additional location CASING(S)
information,a site sketch,and geology on parate page. Diameter / Depth f Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME top
lin.from O to_ _ft. ❑Yes XNo ❑Yes ❑No ❑Unknown
Prope o . :Ir."' if.'-". '. .. . .'1• a.:es'" . r. in.from to ft. ❑Yes ❑No ['Yes ❑No ❑Unknown
11415 Valley Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Rogers, MN 55374 SCREEN/OPEN HOLE
f
Screen from /402, to/eddy ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above y Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)„ 4/4. !b( ¢ igvin
dop
Obstructions removed? 'es ❑No Describe
-- - - - - - - --- - PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing
FORMATION ❑ ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type sue pu fr
• / METHOD USEDTOSEAL ANNUtA
CI
R SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
/' s/ (�>ft 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.)
4 4
Grouting Material C4/ om_e_ to,./66 ft. yards /3 bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? LI 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 Drilling Co., Inc. 1691
Licensee Business N-meLicense or Registration No.
i
'd' -e."s•n at ve Si. a re Certified Rep.No. Date
LOCAL COPY H 3 5 8 3 Name of Peron lin W ll /. 0".S �
6 2 s Sea g e or Boring!
HE-01434-16 ID#53159 : 9n7R