HomeMy WebLinkAbout07/02/2020 - well and boring sealing record -., S MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 375546
WELL OR BORING LOCATION Sealing No."!,-,,,
WELL AND BORING SEALING RECORD
County Name Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series NO.'
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Totrirotgdan Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 05 Pit SW NE 7 . ;?c, 7 -15/
GPS LOCATION-decimal degrees(to four decimal places)
Depth at Time of Sealing 9 7 ft. Original Depth 9-7 ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer 0 Multiaquifer
WELUBORING..--''' ' yr Measured Date Measured "7- r2-,20 0 Estimated
3560 Bayside Rd, orono
VI Water-Supply Well 0 Env.Well
Show exact location of well or boring Sketch map of well or boring ,-,
in section grid with"X." is,.. location,showing property Li Temp .Env.Well El Other V,- ft. X below r]above land surface
N lines,roads,and buildings.
CASING TYPE(S)
1 tz Steel 0 Plastic Li Tile 0 Other
i . .
r . WELLHEAD COMPLETION
w : E T
i Outside: Pitless Adapter/Unit 0 At Grade Inside: 0 Basement Offset
'fi Mile '4 0 Well Pit 0 Buried 0 Well House
1 0 Other 0 Well Pit
S El Buried
I 1 Mile I CI Other
For multiple temporary environmental wells,pr Nide a.."- al location CASING(S)
information,a site sketch,and geology on a se.arate page. Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME Li,/__ in.from K.) to__42._ft. 0 Yes ijki No 0 Yes 0 No 0 Unknown
Wichenhauser Excavating
Properly owner's mailing address if different than well location address indicated above in.from to ft. 0 Yes El No 0 Yes 0 No 0 Unknown
13650 Cty Rd 41 in.from to ft. 0 Yes 0 No EI Yes 0 No 0 Unknown
Cologne, MN 55322
SCREEN/OPEN HOLE
Screen from 5702, to 9 7 ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME .
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions(Describe) i I -* *_..,...".•
Obstructions removed? Si Yes 0 No Describe
PUMP
' • GEOLOGICAL MATERIAL COLOR HARDNESS ORFROM TO 0 Not Present IA Present,Removed Prior to Sealing 0 Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. Type &-, 0.....,---y-,ef•isz.-usa-ift-
0 /7METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
XNo Annular Space Exists 0 Annular Space Grouted with Tremie Pipe Li Casing Perforation/Removal
Casing Diameter
in.from to ft. 0 Perforated 0 Removed
in.from to ft. 0 Perforated 0 Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? Li Yes X No TN#
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Material/X2 41.... ... 6-17,-*--,*om_Cf2to 97 fi. .yards0 .... bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS -
Other unsealed and unused well or boring on property? i''Q YesgNo 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.
Don Stodola Well Drilling Co,. rite -- 1691
Licensee Business Name License or Registration No.
17H
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,,AMIr. - 1
C- ifi:. t•'..esefita ivq,-.9 gnat"Fe - Certified Rep.No. Date
LOCAL COPY H 375546 Name of Person Sealing Well or Boring ''', 60....n.A-.1
HE-01434-16 ID#53159 i...-' 9/17R