HomeMy WebLinkAbout10-06-2020 Well & Boring Sealing RecordHE -01434-17 ID// 53159 V 11/19R
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD Minning No.
Unique Well No.
Minnesota Statutes, chapter 1031 roar W—sseri�swNo.
'.,I 381-37 1 -3 7 %
Q J 1 f
WELLOR BORING LOCATION
benne in
Township Name
Township NoZRange
W.
Section No.
Fraction (sm. — Ig.)
Date Sealed
Date Well or Boring Constructed
Orono
1117
23 1
67
Sh 9, 'k
1 16
GPS LOCATION — decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing 'ft.
Original Depth ft.
AQUIFER(S)
Ingle Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
ry
La Measured Date Measured �`� ❑Estimated
/
4
•! ft. elow ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
kJ 9 tai j 15 o U
ELL/BORING
Water -Supply Well ❑ Env. Well
Temp. Boring ❑ Other
Show exact location of well or boring - Sketch map of well or boring
in section grid with "X." location, showinggg property
N lines, roads, Ildings
CASING TYPES)
Steel ❑,Plastic ❑ Tile ❑ Other
-i----- r-- - - ---t!
I i i I
WELLHEAD COMPLETION
!
W I I E T
; e
T-- ------------i - 1
S
�1 Mile
Outside: itless Adapter/Unit ❑ At Grade Inside: ❑ Basement'Offset
"❑ Well Pit U Buried EI•Vyell House
❑ Other El Well Pit
❑ Buried
.�
El Other
For temporary borings, provide additional location ; 'moi
Information, a site. sketch, and geology on a separate page. [� _...11
CASING(S)
DiargLetr Depth Set in oversize hole? Annular space initially grouted?
in. from to ft. ❑Yeso El ElNo E! Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Property owner's mai Ing a dres i i t th �, o t dr d-dbove
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
1-5235 65th piaca N
in. from to ft. El Yes E) No El Yes ❑No ❑Unknown
Pl a p s e, Grove, It N 55311
SCREEWOPEN HOLE
Screen from to A' ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
YRods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owners address indicated above
Type of Obstructions (Describe)
Obstructions removed? Yes ❑ No Describe
PUMP
Not �y reset, Removed Prio to Sealing
❑t Present n( G. g ❑ Other
Type Z- ; i
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not own, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
Wo Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
as ng Diameter
in. from Ao ft. ❑ Perforated ❑ Removed
in. from to ft. ❑ Perforated ❑ Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes o TN#
GROUTING MATERIA S)
Grouting Material r :om 0 to0-3 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 c 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
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
Is true to the best of my knowledge.
DON S`IODOLA WELL DRILLING CO., INC. 1691
Licensee Business Name License or Registration No.
Ceoeo�. e ase fativeSl�ture Certified Rep. No. Date
6 3
LOCAL COPY
H381377
Name of Person Sealing Well or Boring
HE -01434-17 ID// 53159 V 11/19R