HomeMy WebLinkAbout07-30-19 Well & Boring Sealing RecordHE -01434-16..- ' ID#53159 [ 9117R
# MINNESOTA EPARTMENT OF HEALTH Minnesota Well and Boring.. -
H 365 3 0
LOCATION
WELL OR BORING
�IVELL AND B ING SEALING RECORD MinnSealleso aoUnique Well No.
County Name
tis
Minnesota Statutes, Chapter 1031 or-sere
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Towns ip a Township No. Range No. Section No. Fraction (sm. - Ig.)
Date Sealed
Date Well or Boring Constructed
Orem 1
GPS LOCATION - decimal degrees (to four decimal places)
/
Depth at Time of Sealingft.
Original Depth R.
Latitude Longitude
OUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
C M n , /
Measured Date Measured �('�" Estimated
Numerical Street Address or Fire Number and City of Well or Boring Location
WELL/BORING
4710 Augusta St, Orono
ater-Supply Well ❑ Env. Well
❑Temp. Env. Well ❑Other
- _�__ft. below ❑above iandisuriace
Show exact location of well or boring Sketch ap of well or boring
in section grid with location, showing property
N lines, ro ds, and buildings.
CASING TYPES)
Steel ❑ Plastic ❑ Tile ❑ Other
i ------
WELLHEAD COMPLETION
W E J
-4----
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
i
Is
El Well Pit Buried Well House
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❑ Wel it
S 4
❑ Other
S >
❑ Buried ;
�i Mile ❑
❑ Other
For multiple temporary environmental �ells, ovide additional location
CASING(S)
information, a site sketch, and geology on a se arate page.
Diameter/` / Depth / Set in oversize hole? Annular space initially grouted?
_&Lin. from t/Vto ft. ❑Yes j�No -1Yes ❑ No ElUnknown
PROPERTY OWNER'S NAME/COMPANY NAME
Properly owners mailing a ress if different than well location address indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
18215 45thAveN, Ste D
in. from to ft. E] Yes ❑ No ❑ Yes E1 No El Unknown
='!ty
Plymouth, 55446
SCREEN/OPEN HOLE
t ,
2
from 1G to It. Open Hole from to ft.
WELL OWNER'S NAMEICOMPANY NAMEof
WELL
OBSTRUCTIONS
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owners mailing address if different than property owners address indicated above
Type of Obstructions (Describe)..L/�%!fi!J� !^' � /" �%-0,0
ir
Obstructions removed? Xes ❑ No Describe
PUMP
Not Present Present, Removed Prior to Sealing El Other
❑ 9
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not limown, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNUL R SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ 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 No TN#
GROUTING MATERIAL(S) (One bag of cement = b4 lbs., one bag of bentonite = 50 lbs.)
/
Grouting Materlayw'gr4o�&I&Xorn I/ —, to11-ft. yardbags
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?
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 Well Drilling Co. .Inc. 1591
Licensee Business Pame License or Registration No.
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i e resen 8iiv Signature Certified Rep. No. Date
�_ _ (/t`
LOCAL COPY
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JH 3 6 5 3 0
Name of Person Sealing Well or Bonn
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HE -01434-16..- ' ID#53159 [ 9117R