HomeMy WebLinkAboutWell and Borning Sealing Record Minnesota Well and Boring
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 12 0 0 7 3
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
RennePtn Minnesota Statutes.Chapter 103/ or W-series No.
(Leave blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm. .Ig.) Date Sealed Approximate Date Well
Orono �!1i8 23 31 170 `/f•, a 4, bEC ^5 or Boring Constructed
Numerical Street Address or Fire Number and lCity
�of Well or Boring LocationW " / /
.. 4045 Waterton' Rd, Orono Depth Before Sealing ft. Original Depth ft.
Show exact location of well or boring Sketch map of well or boring Static Water Level X Accurate
in section grid with"X". location.showing property lines.
N roads.and buildings. CIApproximate
If- r
-———
Single Aquifer ❑Multiaquifer I ft. X below above land surface
I
1 CASING TYPE
W E
I 1�
I /L7�Steel CIPlastic 0 Tile 0-Other
1 e mile
/
SScreen from to ft. Open Hole from to ft.
Imo—1rnil �1 I �O.B/STRUCTION/DEBRIS/FILL
Jam'
PROPERTY OWNER'S NAME Obstruction 0 Debris ❑Fill
Bollig Excavating 938.4133
Type of debris/obstructionZA/' • E• IAL/ .
Mailing Address if different than property address indicated above.
Attn: Dan Obstruction/Debris/Fill removed?, Yes ❑No
11401 Cty Rd 3 PUMP
Hopkins, )tl 55343
❑Removed _Not Present 0 Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known.indicate estimated formation log from nearby well or boring. //
DriftIt 0 9 in.from to �� ft. • 0 Yes �No ❑Yes 0 No CI Unknown
i► • in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes 0 No ❑Yes ❑No 0 Unknown
--- _ --- - . -- - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
XNo Annular Space Exists
❑Annular space grouted with tremie pipe •
-- - ❑Casing Perforation/Removal
in.from to ft. 0 Perforated 0 Removed
in.from to ft. ❑Perforated 0 Removed
-- - Type of perforator
❑Other
GROUTING MATERIAL
Grouting material/V.'/C64:1-1"" from Q to 90 ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
/- Other unsealed well or boring on property? 0 Yes XJo
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
Dan Stodola Well Drilling Co., Inc. 21172
Contractor Business Name // License or Registration No.
i 12- 45 .
/7
the.Re resentative Signature Date
LOCAL COPY H 1.2 0 0 7 3 Namea
Jim
L3 of Person Sealing Well or Boring
HE-01434-01