HomeMy WebLinkAbout01/08/21 Well & Boring Sealing RecordWELL OR BORING LOCATION"
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No.
WELL AND BORING SEALING RECORD Minnesota unique Well ND:
Minnesota Statutes, chapter 1037 or W-series No.
(emeaaN if .1 wmm>
H 381514
County Name
Hermep .n
Township Name
Orono
Township No.
1117
Range No.
23
Section No.
109
Fraction (sm. -r Ig.)
,SS /° SH
Date Sealed
Date Well or Boring Constructed
GPS LOCATION - decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing_ _ ft.
AQUIFER(S)
Single Aquifer ❑ Multtaquifer
Original Depth ft.
STATIC WATER LEVEL
Measured Date Measured ) ❑ Estimated
Numerical Street Addressor Fire Number and City of Well or Boring Location
WELL/BORING
Show exact IOCabOn o we or bor ng ap.ei wel or boring?`
in section grid°with "X:' location, showing operty
lines, roa , and b iidings.
N y
9 Water-Supply Well ❑ Env. Well
El Tempi Boring El Other.
_)
ft. [below Elabove land surface
CASINGTYPE(S)
, 1.
Steel ❑Plastic ❑Tile' ❑ Other '
WELLHEAD COMPLETION
Outside: / Pitless AdapterNnit ❑ At Grade Inside: ❑ Basement Offset
/❑_Well
?h Mile
##
- -s
Pit ❑ Buried ❑ Well House
El Well Pit
El Other
❑ Buried
I 1 Mile
t.� s
El Other
For-temporary borings, provide additional location 14dCASING(S)
information, a site sketch, and geology on a separate page.
Di er Depth _ Set in oversize hole? Annular space initially grouted?
in, from -) toft. ❑ Yes rXo '' El Yds, ` [:1 No El Unknown
in. from to ft. El Yes ❑ No ❑ Yes ❑ No ❑Unknown
PROPERTY OWNER'S NAME/COMPANY NAMEy��
O & - Z as
Property owner's mailing address if different than well location address indicated above
18212 om Blvid
Deepbavenj M 55391
in. from to ft. ElYes ❑ No ElYes ❑ No [:1Unknown'
SCREEWOPEN HOLE
Screen from to IIIft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY
'NASsME o
B SJ & a �[1ie Heffes
,,,,O-BSTRUCTIONS
pO Rods/Drop Pipe El Check Valve(s) Debris El Fill El No Obstruction
rType
Well owners mailing address if different than property owners address indicated.above
f❑j
of Obstructions (Describe)
Obstructions removed? gYes ❑ No Describe
I
PUMP
❑ Not Present {Present, Removed Prior to,Sealing ❑ Other
Type, ,-- •y y.` ,
GEOLOGICAL MATERIAL
COLOR
HARDNESS ORFORMATION
FROM
TO
If not known,' indicate estimated
formation log from nearby well or boring.
j
y r"METHOD
i
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/ReImovai
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? ❑ Yeso TN#
GROUTING MATERIAL(S)
Grouting Material 'y r civ ° frofi = 40 yards f 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 XNo 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 SM' W DR1U. # ; =Ct 1.69.1
Licensee Business N e License or Registration No.
y
ili F7e/iresentalive Signe `` Cethfied Rep No " Date `
LOCAL COPY
H
3815 4
f
Name of Person Sealing Well or Boring
HE -01434-17' ID# 53159
it.