HomeMy WebLinkAbout12/30/20 Well & Boring Sealing Record11/79rt
HE -01434-17 IDN 63159 ' Aj ,
MINNESOTA DEPARTMENT OF HEALTH 1411Dn8Sofa Well and Boring
WELL AND BORING SEALING RECORD 'Sealing
nesot, No.
well No.
Minnesota Statutes, chapter 1037 •• or W-series No.
i� (Leave Wank Hoot known)
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WELL BORING LocaTloN
Na
County Name
{{ �gyyyy
3�,n.i7.•Fi
Township Name
Orono
Township No. `
1173
Range No.
Section No.
J7
Fraction (sm. -'Ig.)
AW M &
Dafe Sealed
Date Well or Boring Constructed
GPS LOCATION - decimal degrees (to four decimal places)--
Latitude Longitude
Depth at Time of Sealing ft.
3
Original Depth—- ft.
Numerical Street Addressor Fire Number and City of Well or Boring Location
1366 Rest Point & Oroao AM
AQUIFER(S)
Single Aquifer ❑ Mulltaquifer1
STATIC WATER LEVEL
A
Date Measured "rtat �T []Estimated
% ft. below ❑ above land surface
W€LL/BORINGMeasured
Water-Supply Well❑Env. Weil -
Tem Boring Other
p g ❑
Show exact location of well or boring Sketch map'of well or boring
in section grid with "X." t5 }},, location, showing property
CASINGTYPE(S)
N+a lines, roads, and buildings.
Steel ❑ Plastic ❑ Tile ❑ Other
-*+4
WELLHEAD COMPLETION
W E
TOutside:
h Mlle `�
,
ElPitless Adapter/tJnit • El Grade Inside: [ Basement Offset
E] Pi Pit ❑Buried ❑ Well House
El Well Pit
s
❑ Other
❑ Burled _ ..
f1 rutile— --{
❑Other
For temporary borings, provide additional loc on
information, a site sketch, and geology on a s parate page.
CASING(S)
Dia ter ` Depth Set in oversize hole? Annular space initially grouted?
in.,from to _ ft. ❑ Yes No ❑ Yes ❑ No . ❑ Unknown
PROPER Y OWNER'S NA EICOMPANY AME
in. from to it. ElYes ElNo El Yes [-INo. : ❑ Unknown'
Property owner's mailing address if different th n el` cation address indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
Screen from_ toff. Open Hole from to ft.
WELL OWNER'S NAMEJCOMPANY NAME
OBSTRUCTIONS
V Rods/Drop Pipe ElCheck Valve(s) ❑ Debris . ❑ Fill El No Obstruction
YT'
Well owner's mailing address if different than property owner's address indicated above
t
Type of Obstructions (Describe)
Obstructions removed 15(Yes ❑ No Describe
PUMP s
❑Not Present .Present, Reino'ved Prior to Sealing El Other
Type Lz
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING-AND BORE HOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
GEOLOGICAL MATERIAL
COLOR
HAflDNESS OR
FORMATION
FROM
TO
if nol nown, indicate estimated formation log from nearby well or boring.
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 o TNN
GROUTING MATERIAL(S)
GroutingMaterial-AJ-& tfrdkn to ft' Yards bags
from to f(. 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
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.
REMARKS, SOURCE OF'DATA, DIFFICULTIES IN SEALING
DOX STOPOLA. WELL RRIULING CO.* INC, 16' 1_
Licensee Business Name License or Registration No.
5567e
rtirr Represen ativ Si alure Certified Rep. No. Date'
& tn�.'
LOCAL COPY
H 381412Name
of Person Sealin Well or Borin
9 9 '•
11/79rt
HE -01434-17 IDN 63159 ' Aj ,