HomeMy WebLinkAbout12-21-2020 well and boring sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 81 4 9 2
WELL AND BORING SEALING RECORD
County Name MinnlesotaoUnique Well No.
Minnesota Statutes,chapter 1031 or W serieskN o.
(Lve blank II notJ1 nnopfr
Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
Ornnc3 117 73 17 0.—§W ' /01 .2/ -- t''
GPS LOCATION-decimal degrees(to four decimal places) /
Depth at Time of Sealing f 43L ft. Original Depth _ ft.
Latitude Longitude
�A-Q{UIFER(S) STATIC WATER LEVEL
Numerical Street Address or ire Number and City of Well or Boring Location Lr Single Aquifer ❑Multiaquifer j J )�
WELL/BORING ,Measured Date Measured i J Oz ❑Estimated
3520 Livingston-Ave* Orono 0 Water-Supply Well ❑Env.Well. • '
Show exact location of well or boring ' Sketch map of well or boring ,--, ���/// '
in section grid with"X" location,showing property ❑Temp.Boring EI Other - '7 ' ft. Ly below ❑above land surface
N lines,roads,and buildings. CASINGTYPE(S) f •
*----] Steel El Plastic Li ❑Other
--- '-- '-- --------- WELLHEAD COMPLETION •
w E '�
T
Outside:'❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset
Mile ❑Well Pit ❑Buried WellHouse
r 1
❑Other ❑Well Pit
. S ❑Buried
I • 1 Mile —I 4,::,) ,
/�( ❑other
For temporary borings,provide additidithl lbc`ation 4-,
VaCASING(S)
information,a site sketch,anmet
d geology on a separate pe. Dialer Depth Set in oversize hole? Annular space initially grouted?
1 /
PROPERTY OWNER'S NAME/COMPANY NAME in.from `� to /Ii
e7 ft. ❑Yes 'INo ❑Yes ❑No ❑Unknown
Trin T*wisstu is TTI!
Property
owner's mailing address if �V2t
different than well location address indicated above in.from to ft. ❑Yes ❑No El Yes Yes No ❑Unknown
34 13th Ave NE, Ste 80in.from to ft. ❑Yes ❑No ❑Yes ❑No
'j ❑Unknown
Minneapolis, Iti 55413 SCREEWOPEN HOLE '
WELL OWNER'S NAME/COMPANY NAME Screen from / f/0 to *C)` 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 El Fill ❑No Obstruction
T 11 `
Type of Obstructions(Describe) Kt-a, , -C.--_-_, -.5,--
Obstructions removed? 'Wes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present , [ 'resent,Removed Prior to Sealing❑ ❑Other
If not nown,indicate estimated formation log from nearby well or boring. Type -"h. 9_k
/A--' 0 (, 1,8,1 METHOD USED TO kAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
[ Vo Annular Space Exists ElAnnular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
f asing Diameter
i in.from to ft. ❑Perforated ❑Removed
in.from_ to ft. ❑Perforated ❑Removed
Type of Perforator
VARIANCE ,�f'
Was a variance granted from the MDH for this well? ❑Yes [?No TN#
-GROUTING MATERIAL(S) _./. s / '7
Grouting Material /1)'1 i it.. (;) ; o fLm ("s to f,":;.*1 ft. yards_ bags
9
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 T
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
f"-...-7,74-7-7"-"
License or Registration No.
`_,..,1/7„' '.�C �i- / j4. ! al" '- fes,
Ce _ed fiepfesentative Signetur "' ' Certified Rep.No. Date j
p
LOCAL COPY H 3 8 1 4 9 2 .., ,. .
-,.. .)..f,,,,,,A / (:-0,,,,.._,
', ", ,-.'
Name of Person Sealing Well or Boring /
HE-01434-17 ID#53159 11/19R