HomeMy WebLinkAbout2019 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boringt'�
WELL OR BORING LOCATION H 7 0 LD J
WELL AND BORING SEALING RECORD Sealing No.
County Name Minnesota Unique Well No.
jj,�� ��jj Minnesota Statutes,Chapter 1031 oraW-seriesNo.
TowfiS TPIATownship No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed / ! Date Well or Boring Constructed
1�1117� � y},7 14 ,4 ,ti /6//y I/ 9
GP i &-decimi a lees(to;our decimal places) 1W1414
/
Depth at Time of Sealing 95 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City ofWell or Boring Location Single Aquifer ❑Multiaquifer
•�y/,ar�r0��'�/"��a_, 4 ., civr„ LUBORING X.Measured Date Measured �� ❑Estimated
1 t►1 Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring �� �D below ❑above land surface
in section grid with"X." location,s wft. 1F'ing pro er Temp.Env.Well ❑Other
lines,roa and buil,I
N (1.„07—1 -/' (- J -,ice CASING TYPE(S)
I yr Steel ❑Plastic ❑Tile ❑Other
---1-"'--'--- -`--'-- --' WELLHEAD COMPLETION
w E T Outsider Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
Mile Well Pit ❑Buried WellHouse
h ❑ ❑
r - 1
❑Well Pit
d ❑Other
s ❑Buried
Mile )
❑Other
For multiple temporary environmental wells,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. Diameter /
NY NAME Depth , Set in oversize hole? Annular space initially grouted?
PROPERTY ER'S NAME/COMP / Q
��Q _ea___in.from � to F/ ft. ❑Yes �No ❑Yes ❑No El Unknown
%
Prone Stf e"s if differentt�hhaan well location address indicated above in.from to ♦ ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1825 Pagsrn6N Point Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Orono PIR 551 SCREEN/OPEN HOLE
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WELL OWNER'S NAME/COMPANY NAME Screen from 9/ to15 ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above WRods/Drop Pipe ❑CheckkV^^��alve(s) ❑Debris El Fill ❑No Obstruction
Type of Obstructions(Describe) ` J44) /Q / '/ 4 19141411P
Obstructions removed?X Yes D No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION Li Not Present Present�,yRemoved Prior to Sealing ❑Other
If nqt known,indicate estimated formation log from nearby well or boring.At4 - Type jik SU(� !/t 1 �
C/..�yj 0 y� METHOD USED TO SEAL ANNULLAR4,rSPAC BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe Xing Diameter ❑Casing Perforation/Removal
sing 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- 4 lbs.,one bag of bentonite=50 lbs.)
I •
Grouting Material from_ to 94 ft. yards_2O_ 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 '�Jo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION J(
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 Stodoln Well Drilling Co,. Inc. 1691
Licensee Business Name License or Registration No.
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