HomeMy WebLinkAboutWell Boring & SealingMINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL OR BORING LOCATIONSealing oH 3699d, r 2
County Name WELL AND BORING SEALING RECORD Minnesota Unique
Minnesota Statutes, Chapter 1031 or W -series No.
(U— ea* a W w--)
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tot xi-"- a' Township No. Range No. Section No. Fraction (sm. Ig.) Date Sealed Date Well or Boring Constructed
d d u
T
ATION - decimal agrees (to tour 2ecimai places)
Depth at Time of Sealing Original Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Mulllaquifer
420 Lakeview Parkway, Orono WELUBORING >0 Measured Date Measured '7.4 MA Estimated
Water -Supply Well ❑ Env. Well ♦
Show exact location of well or boring Sketch map of well or boring
in section grid with "X.° 3 location, showing property ❑ Temp. Env. Well ❑ Other below [-]above land surface
N% lines, roads, and buildings. CASINGTYPE(S)
r
Steel ❑ Plastic ❑ Tile ❑ Other
i -- - -- ---t-- J WELLHEAD COMPLETION
W E
Outsider Pitless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset
h Mile $Well Pit ❑Buried ❑
❑ We House
Well Pit
F-1 Other
s ? Y
�1 Mitek r;�
For multiple temporaryenvironmental wells,
information, a site sketch, and geology on a
11r
rovide additional location
eparate page.
❑ Burled
❑ Other
CASING(S)
Diameter� ♦ Depth ♦ Set in oversize hole? Annular space initially grouted?
� in. from_ _ to, 1__ ft. Elrs)t Yes No ❑ Yes ❑ No ❑ Unknown
in. from to ft. El Yes El No ❑ Yes No ❑ Unknown
in. from to ft. ElYes ElNo ❑ Yes ❑ No E]Unknown
PROPERTY OWNER'S NAMEICOMPANY NAME
AT TT
ri§
Pr ol's ma Gress if different than well location address indicated above
1�2J11. c titJ 45thAve N,� GSte r
Plymouth, MW 5944&
SCREEWOPEN HOLE
Screen from to ft. Open Hole from to 29 ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction
Type of Obstructions (Describe)
Obstructions removed? ❑ Yes ❑ No Describe
Well owner's mailing address if different than property owner's address indicated above
PUMP
Not Present Present, Removed Prior to Sealing
❑ g ❑ Other
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
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METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal
Casing Diameter
in. from to ft. ❑ Perforated ❑ Removed
in. from to ft. ❑ Perforated ❑ Removed
Type of Perforator
/
.lf s + •
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes XNo TN#
GROUTING MATERIAL(S) (One bag of cement = 04 His., one bag of bentonite = 50 lbs.)
— , / p r
Grouting Material/,/4,q aIYXL)/ from c/to .7-17 R. yards 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 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
is true to the best of my knowledge.
Don Stodola Well Drilling Co,. Inc. 16%
REMARKS, S gE DF�OATA, DIFFICULTIES IN SEALING
.,_..,. ..
APRQ 3 2020
CITY OF O RO �o
Licensee Business Name License or Registration No.
ied R6presen ali6e Signature Certified Rep. No. Date
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LOCAL COPY
H
6 �"
1." 0 `-C 2
Name of Person Sealing Well or Boring
HE -01434-16 ID# 53159
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