HomeMy WebLinkAbout03-09-20 Well & Boring Sealing RecordMinnesota
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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. and Boring H 37277
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County Name -WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 �r W�*0W No.
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Orme In
Township Name Township No. I Range No. Section No. I Fraction (sm. - Ig.) Date Sealed Date Well or Boring Constructed
Orono 1 117 23 107 c*1 sF. w, p Q
GPS LOCATION - decimal degrees (to four decimal places)
Depth at Time of Sealing Q�ft. Original Depth tt.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer {
WELL/BORING Measured Date Measured) r)h� ❑ Estimated
I A( Water -Supply Well El Env. Well
S ow exact location o(we�l or boring Sketch map of well or boring ❑Temp. Env. Well El Other ft. below
in section grid with "X" locati n, showing property ❑ above land surface
N lird�ds, and buildings. CASING TYPES)
-`
Steel E] Plastic El Tile [_1 Other
--- -- --- ----------
WELLHEAD COMPLETION
W E
i } I T } Outside: ❑ Pliless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset
'h Mile O LlWell Pit Buried Well House
❑ Well Pit
1 ❑ Other
s ❑ Buried
�1 Muer ❑ Other
For multiple temporary environmental wells, provide additional location CASING(S)
information, a site sketch, and geology on a separate page. Diameter r Depth / Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME I I in. from_8 to dip_ ft. ❑ Yes No ❑ Yes [I No ❑ Unknown
P ne ' i dRVMAd1JAtrCWgddress indicated above✓ in. from to 1� ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
X16230 54th St in. from to ft. E] Yes ❑ No ❑ Yes El No El Unknown
St. Michael, T 55376 SCREEWOPEN HOLE `
WELL OWNER'S NAME/COMPANY NAME WELL
from-50 to 43(/ it. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
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Type of Obstructions (Describel til A"- n '-/6r
Obstructions removed? es ❑ No Describe
'i PUMP
GEOLOGICAL MATERIAL I COLOR HFORMATIONR FROM TO 1 1 4 Not Present ❑ Present, Removed Prior to Sealing ❑ Other
If not known, indicate estimated formation log from nearby well or boring. Type
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
sing Diameter
In. from to ft. [J Perforated ❑ Removed
in. from to ft. E]Perforated ❑ Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes OK
No TWl
GROUTING MATERIAL(S) (One bag of cement = 94 lbs., one bag of bentonite = 50 lbs.)
f�
Grouting Material a from to 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 No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING 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.
Dan Stodola Well Drilling Co,. Inc. 1691
Licensee Business Name License or Registration No.
3-10-20
Ile
epresenta ' gn e \ Certified Rep. No. Date
{, 7 'Jim Antonson
LOCAL COPY JH 3 7 2 7 i! 1 Name of Person Sealing Well or Boring
HE -01434-16 ID# 53159 9/178
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