HomeMy WebLinkAboutWell Boring & SealingHE -01434-16 ID# 53159 ( �% 9117R
MINNESOTA DEPARTMENT OF HEALTH Mi Ing Nowell and Boring
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 or W--sse„ieswNo.
H 3 � -274.3
WELL OR BORING LOCATION
County Name
T
y!�►1 Ai'
Township Nam
Township No.Range
No.
Section No.
Fraction (sm. Ig.)
Date Sealed))
Date Well or Boring Constructed
n
.:�ti t it.T t.1
�C - 3 %,L),26
GPS LOCATION - decimal degrees (to four decimal places)
Latitude Longitude
t
Depth at Time of Sealing 1 Q if ft.
Original Depth
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
_ L2d�Q Measured Date Measure' Estimated
It. below above land surface
❑
Numerical Street Address or Fire Number and City of Well or Boring Location
1-398 Rest Point Rd- Orono -
WELLBORING
g Water -Supply Well ❑ Env. Well
ElTemp. Env. Well ❑ Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X.° location, showing property
tines, roads, and buildings.
N 1
'--- --y-- - `- -
j
CASINGTYPE(S)
Steel ❑ Plastic ❑ Tile ❑ Other
--i--- ---- --`--
WELLHEAD COMPLETION
W E�
I I
--�------t
'h Mile
-:--- --
1
S
Outside: Pitless Adapter/Unit ❑ At Grade Inside: El Basement Offset
E]t
Well Pit ❑ Buried ❑ Well House
❑ Well Pit
El Other
❑Buried
I--1 Mile
❑ Other
For multiple temporary environmental wells, provide additional location
CASING(S)
information, a site sketch, and geology on a separate page.
Diameter Depth Set in oversize hole? Annular space initially grouted?
in. from to ft. ❑ Yes No E] Yes ❑ No El Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
La
in. from to ft. ElYes E]No E]Yes [-]No ElUnknown
ProjKlrlsiklllng address if ifferent than well location address indicated above
11401 Cty Rd. 3
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Hopkins, W 55443
SCREEWOPEN HOLE
Screen from /09 L to 11JR ft,Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
IF7 Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owners mailing address if different than property owner's address indicated above
Type of Obstructions (Describe) _ )
Obstructions removed? Yes ❑ No Describe
PUMP
❑ Not Present Present, Removed Prior to Sealing ❑ Other
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If nol known, Indicate estimated formation log from nearby well or boring.
Q
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists El 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 X,No TN#
GROUTING MATERIAL(S)11 (One bag of cement = 94 lbs., one bag of bentonite = 50 lbs.)
Grouting Material- 0-4, r-2, trom—�/ to /1J-& ft. 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 VNo 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.
REMARKS, SOURCE OF DATA, bIFFICu L•S IN SEALING
1,
Ton Stodola Well Drilling Co. Inc. 1691
APR 0 3 2020
Licensee Business Name License or Registration No.
CITY OF ORONO
.'���
C rfi re'sentativ i att re Certified Rep. No. Date
LOCAL COPY
H72743
Name of P rson Sealing ell or Boring
HE -01434-16 ID# 53159 ( �% 9117R