HomeMy WebLinkAbout04/24/2020 - well and boring sealing record Minnesota
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No.Well and Boring H 3 7 5 4 3 9
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 o aW series.No.
k if not Or)
T wnship NaRein Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 17 SO th 7 it - , t/ - `-
GPS LOCATION- decimal degrees(to four decimal places) / /
Depth at Time of Sealing l`� ft. Original Depth ft.
Latitude Longitude
AO IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ,�( '")�,/ ..
q�� ELLBORING ={(�Measured Date Measured f ';fi / 'C.-A) ❑Estimated
34s�7 Crystal Ray M t Ornno Water-Supply Well ❑Env.Well l�
Show exact location of well or boring Sketch map of well or boring �- yam'below ❑above land surface
in section grid with"X." �r location,sh• ing property ❑Temp.Env.Well ❑Other ft. XX``•
N E f ines40oad. and bui•A '•• CASING TYPE(S)
(... /4 Steel ❑Plastic ❑Tile ❑Other
W
--,-----,------------ ---E .-r-.,.i WELLHEAD COMPLETION
Outside: ❑Pities Adapter/Unit ❑At Grade Inside: ❑Basement Offset a-,�
h Mile ❑Well Pit ❑Buried ❑Well House r ,,
Li Well Pit
1. ❑Other
S ❑Buried j
t Mile--I
s,Other <1....f, 13e./ ..:1 ''1"
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?
PROPERTY OWNER'S NAME/COMPANY NAME in.from t", to 1) '717 ft. ❑Yes o ❑Yes - ❑No ❑Unknown
Prope Towne s mai mgiddressifdirenT l�ialfR�aela iodre�ss indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
4741 S Lake Sarah Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Maple Plain, M 55359 SCREEWOPEN1HOLE ,
WELL OWNER'S NAME/COMPANY NAME Screen from / / to i'•� I ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above Vods/Drop Pipe ❑Check Valve(s) jjj❑Debris El Fill ❑No Obstruction
Type of Obstructions(Describe) (1--t
'JC ,+ l�}
Obstructions removed? 'ces ❑No Describe \
PUMP
GEOLOGICAL MATERIAL COLOR I HARDNESS OR I FROM TO Not Present 'Present,Removed Prior to Sealing
FORMATION ❑ ❑Other
Ott,
If not known,indicate estimated formation log from nearby well or boring. Type _
♦ I pf METHOD USED T_ EAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
asing 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 I No TN#
•
GROUTING MATERIAL(S) (One bag of cement_-9944 lbs.,one bag of bentonite=50 lbs.)
Grouting MaterialAh4 JWI O 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? ❑YesNo 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. Inc. 1691
Licensee Business Name License or Registration No.
- ,. 'resent-ti4.tg,'Inrc-..- Certified Rep.No. Date
LOCAL COPY H 3 7 5 4 3 9
Name of Person Sealing Weer Boring AAA...)
HE-01434-16 ID#53159 \j S.,....r 9/17R