HomeMy WebLinkAbout04-07-2021 Well & Boring Sealing RecordHE -01434-17 ID# 53159 11/191`1
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealonry
WELL AND BORING SEALING RECORD Minnleso a UNnique Well No.
Minnesota Statutes, chapter 1031 or W-sse„i es No.
H 381599
mBORING LOCATION
OELL
T-Torinnain
Township Name
Township No.
Range No.
Section No.
Fraction (sm. - Ig.)
Date Sealed
Date Well or Boring Constructed
n
lfl tl "'M
417121
GPS LOCATION – decimal degrees (to four decimal places)
LatitudLongitude
e
Depth at Time of Sealing 19 ft.
Original Depth ft.
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
Measured Date Measured 1) �! `� El Estimated
�ft.] below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
q Crystal Place Orono
LLBORING
19 Water -Supply Well ElEnv. Well
E]Temp. Boring . ❑ Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X." location, showing property
lines, roads, and buildings.
N i 1 �
--- --- -- ---L------
CASINGTYPE(S) ,
® Steel ❑ Plastic ❑ Tile ❑ Other
i--- --i--- --- L - ---a
WELLHEAD COMPLETION
W , ET �.
4--- --; 1- -- ---f--
'k Miley
S 1
G
I— —t Mneme �r{__�
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
Well Pit Buried Well House
[ El
nn
❑ Well Pit
E] Other
❑ Buried
El Other
CASING(S)
For temporary borings, provide additional location
infprmation, a site sketch, and geology on a separate page.
Diameter Depth Set in oversize hole? Annular space initially grouted?
_ in. from to 1€16 ft. E] Yes E] No ❑ Yes ❑ No Unknown
PR PERTY-OWNER'S NCO PANY NAME
LaCZAA 1*
1-1
Property dwner`smaili adKell diltere t an weu wcatio address Indicated above
in. (tom to ft. ❑ Ye5 ❑ No ❑Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
Screen from to---190—ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill EX 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
[R Not Present ❑ Present, Removed Prior to Sealing ❑ Other
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
[X No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
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? ❑ Yes [:ro TN#
GROUTING MATERIAL(S)
Grouting Material tgeat Cerleent from_ to--j–W ft. yardsST 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 gJ 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
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
is true to the best of my knowledge.
Don Stociola Well Company 1691
Licensee Business Name License or Registration No.
4/7/21
esirtif6d'R %sen five $!g Certified Rep. No. Date
Jerry Barr
LOCAL COPY
H (
5 .. J 9
Name of Person Sealing Well or Boring
HE -01434-17 ID# 53159 11/191`1