HomeMy WebLinkAbout05/08/2020 - well and boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 7 5 4 5 5
WoE ri o NamSealinsNo.
BORING LOCATION WELL AND BORING SEALING RECORD Minnesota Well No.
Cq �t e
Minnesota Statutes,Chapter 103 or W s eries No.
L�1.lYi�EPIA
Township Name Township No. Range No. Section No. Fraction(sm.- Ig.) Date Sealed Date Well or Boring Constructed
DRUN0 117 23 10 Sw'AN Nt - -' A 15
GPS LOCATION-decimal degrees(to four decimal places) y -'
Depth at Time of Sealing �:r) ft. Original Depth ft.
Latitude Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer _
WELL/BORING yMeasured Date Measured ✓ `- iii Estimated
1150 Heritage Ln Orono, *1Nf7JWater-Supply Well E]Env.Well
Show exact location of well or boring Sketch map of well or boring (/),- .4
/
in section grid with"X" _ location,showing property ❑Temp.Env.Well ❑Other (!1 ft. below ❑above land surface
lines,roads,and buildings.
NI 1'. ,..4,- CASINGTYPE(S)
- • ` Cr
J �! Steel ❑Plastic ❑Tile ❑Other
--------'---•------------ `^� (W�ELLHEADDtCOMPLETION
w I I E T �{ , \ Outside:Ar Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'/,Mi. ) 1 ❑Well Pit ❑Buried ❑Well House
---
t ❑Other ❑Well Pit
s ❑Buried
I 1 Mile I 1.
❑Other
For multiple temporary environmental w. provide additional location CASING(S)
information,a site sketch,and geology o .a eparate page. Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY�{ NAME.(( Lit{ 'Tj (� in.from r_'3 to / 79 ft. ❑Yes y No ❑Yes ❑No ❑Unknown
gti ff 4 wv.AIQdSRt dl
Property owner's mailin a di an ad ,ii ibated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
10425 Bluff Road in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Eden Prairie,. t4( 55347 SCREEWOPEN HOLE
WELL OWNER'S NAME/COMPANY NAME Screen horn f 7 j to /r' 3 ft. 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
Type of Obstructions(Describe) d•,.--� - .—
Obstructions removed? ' Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to SealingOther
FORMATION ❑ ❑
If not known,indicate estimated formation log from nearby well or boring. Type , 't r ,. aJ S. ..i ..a-
,r-y A-� �1 !-t 3 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
CEJ •.i t fiL_ Pipe Space Grouted with Tremie K No Annular Space Exists ❑Annular p ❑Casing Perforation/Removal
1 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? ❑YesNo TN#
-- - GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
Grouting Materia 0,4 l)0-em--r.:. from (') to /e--3 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.
DON STODOLA WELL DRILLING -CO. , INC, 1691
Licensee Business Name // License or Registration No.
` ` '� 'X- 553
dints eSiyna`fu i Certified Rep.No. Date
LOCAL COPY H 3 7 5 4 5 5 �, ,_r,�.,_4 / _APA)
Name of Person Sealing Well°Oaring l
HE-01434-16 ID#53159 '---' 9/17R