HomeMy WebLinkAbout09-17-2018 - well & boring sealing record Minnesota
WELL OR,BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No.
and Boring 3 5 5 5 5 4
Coultty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or w e erier No.
Hennepin
Township Name Township No. Range No. Section No. Fraction(sm.-n Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 07 N` SL NE 9 1/7/i9 .
GPS LOCATION-decimal degrees(to four decimal places)
Depth at Time of Sealing 951 ft. Original Depth ft.
Latitude Longitude
OUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location (Single Aquifer Multiaquifer ^
1151 North Arm nr, Orono 55364 C WELL/BORING - 'Measured Date Measured SA/YV / i*" ❑Estimated
s Water-Supply Well ❑Monit.Well e
Show exact location of well or boring Sketch map of well or. rl,• /-�
in section grid with"X" location,showing grope y Env.Bore Hole ❑Other -/5 ft. Ybelow ❑above land surface
lines,roads,and¢rgldi s
N CASING TYPE(S)
•,2 (rrt; Steel Li]Plastic ❑Tile ❑Other
--'-----'------`--•------ WELLHEAD COMPLETION
W E
---i__-,---r--,__-;_-__--_-• Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'h Mile LIWell Pit ❑Buried ❑Well House
❑Well Pit
❑Other
9 - I ❑Buried
-
� t Mile-�
❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Paul VO Strom Diameter / Depth Set in oversize hole? Annular space initially grouted?
Property owners mailing address if different than well location address indicated above y ,in.from Q to 90 ft. ID Yes *No ❑Yes ❑No ❑Unknown
10231 Beebe Lake Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Hanover, MN 55341
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
•
Well owner's mailing address if different than properly owner's address indicated above Screen from l�' to �� ft. Open Hole from to ft.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill Ago Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe
FORMATION
PUMP
If not;tcnown,indicate estimated formation log from nearby well or boring.
Wot Present ❑Present,Removed Prior to Sealing ❑Other
d A i 0 ->y Type
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
(l Callo 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? ❑Yeso TN#
GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.)
•
Grouting Materialp,L�CA G/UI from d to q 14 ft. yards_ ' bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yeslo 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
is true to the best of my knowledge.
Don Stodola Well Drilling Co., Inc. 1691
Licensee Business Name License or Registration No.
'
`/ ii_� /�
2ntaiveSighature Certified Rep.No. Date
LOCAL COPY H . i r. / �// jtd Q,SY•��
3 5 5 55 4 Name of Person Sealing We or Boring
HE-01434-15 Da 53159 k, 9/1611