HomeMy WebLinkAbout10-04-19 Well & Boring Sealing RecordHE -01434-16 ID# 53159 9/17R
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
SealWELL AND BORING SEALING RECORD Minnesota aoUnique Well No.
Minnesota Statutes, Chapter 1031 or W—sseries No.
i 0 i 1 (`
H 370056 ( lJ �)
WELLORBORINGLOCATION
Name
T
Township Name
Township No.
Range No.
Section No.
Fraction (sm. —r Ig.)
Date Sealed
Date Well or Boring Constructed
Ornn
117
23 107k
b E'
GPS LOCATION — decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing�_ft.
Original Depth ft.
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
/�
Measured Date Measured 5MI bA El Estimated
f
ft-)Cbelow ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
r�
Q Park DC O ow
ELL/BORING
Water -Supply Well ❑ Env. Well
❑Temp. Env. Well ❑Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X" linesn, showing property
N , roads, and bu.'dings'
CASING TYPES)
Steel ❑ Plastic ❑ Tile ❑ Other
___ __a__ ----------- 4__
W E @ '
__ ___r__ T
'h Mile
r 1
s
WELLHEAD COMPLETION
Outside:�PitI ess Adapter/Unit ❑ At Grade Inside: El Basement Offset
❑ Well Pit ❑ Buried ❑ Well House
Other ❑Well Pit
❑ Buried
�1 Mile
For multiple temporary environmental well , proro'vl"de ad 1 lona I ca loris �
information, a site sketch, and geology on a separate page.
❑ Other
CASING(S)
Diamelel f _e if Depth / Set in oversizte hale? Annular space initially grouted?
�— in. from_�� tot ft. ❑ Yes ][I No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes /�❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Norton Rmes
Property owner's mailing address if different thanwell location address indicated above
1._8215 455th Ave N. /•.Iia D
Plymouth, M 55446
WELL OWNER'S NAME/COMPANY NAME
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
I
Screen from to� ft. Open Hole from to I.
OBSTRUCTIONS
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owner's address indicated above
Type of Obstructions (Describejl 11J41,4 02&09� ¢ A~
Obstructions removed? X Yes ❑ No Describe
PUMP
❑ Not Present Present, Removed Prior to Sealing ❑ Other
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not Known, indicate estimated formation log from nearby well or boring.
"
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
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 yNo TN#
GROUTING MATERIAL(S) (One bag of cement = lbs., one bag of bentonite = 50 lbs.)
Grouting Material AC��t from Q / to�-0 `ft. yards_ R 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 ANo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed In accordance with Minnesota Rules, Chapter 4725. The information contained In this report
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
is true to the best of my knowledge.
Don Stodola Wa11 Drilling Co,. Iw.- 16%
Licensee Business Name License or Registration No.
d e A t a Signature Certified Rep. No. Date
1
LOCAL COPY
H 7
�.` �J V
Name of Person Sealing Well or Darin
HE -01434-16 ID# 53159 9/17R