HomeMy WebLinkAbout09-02-2021 Well & Boring Sealing RecordHE -01434-17 ID# 53159 i I/19H
Minneso
MINNESOTA DEPARTMENT OF HEALTH Sealing to Well and Boring
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, chapter 103/ �r W .*9-1 ori
I I 4� Q (l
(? 1 1 �1
WELL OR BORING LOCATION
County Name
ITnn n-
Township Name
Township No.
Range No.
Section No.
Fraction (sm. - Ig.)
Date Sealed
Date Well or Boring Constructed
Orono
117
I 23
07
1 SF SW 'uS
9/2/21
GPS LOCATION — decimal degrees (to four decimal places)
n L
Depth at Time of Sealing C] � ft.
Original Depth ft.
Latitude Longitude
AQUIFER(S)
KI Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
Measured Date Measured) 2 21 E] Estimated
3 2 t1. RJ below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
1390 Rest Point Rdo Orono
WELUBORING
® Water -Supply Well ❑ Env. Well
❑ Temp. Boring ❑ Other
Show exact location of well or boring Sketch map of well or borirr��gg
in section grid with "X." location, showing props riy
CASINGTYPE(S)
Steel ❑ Plastic ❑ Tile ❑ Other
N 5361 lines, roads,Idbyfldngs.
-1--]
WELLHEAD COMPLETION
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
❑ Well Pit ❑B uried Well House
❑ Well Pit
<
W i E
f , T
vz Mile
—% I
T
L
s
❑ Other
❑ Buried
—t Mile y
jo Other f- CAW PACE
CASING(S)--
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.
Diameter 4 Depth n Set in oversize hole? Annular space initially grouted?
3 in. from 1 to Q O ft. ❑ Yes ❑ No ❑ Yes ❑ No Xj Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Property owner's mailing address if different than well location address Indicated above
in, from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
WELL OWNER'S NAME/COMPANY NAME
�'
Screen from to ---91-4-11. Open Hole from to ft.
OBSTRUCTIONS
ja Rods/Drop Pipe ❑ Check Valve(s) Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owners address indicated above
1,❑
Type of Obstructions (Describe) drop )tfte
Obstructions removed? W Yes ❑ No Describe
PUMP
Not Pt, Roved Prior to Sealing El Other
Present, em
❑ resent Pg
Type e t pump
GEOLOGICAL MATERIAL
COLOR
Hon
FORMATION
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
drift
O
84
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE
® 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 ❑ No TN#
GROUTING MATERIAL(S)
Grouting Material iiTo A t r Mn n trom--I_ to A4 n. yards_4 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 id 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
Don Stodola Well Drilling Co Inc 1691
Licensee Business Name p License or Registration No.
,/r 553 9/2/21
rtified epresentafive Sign tore Certified Rep. No. Date
Jerry Barr
LOCAL COPY
JH g 6
Name of Person Sealing Well or Boring
HE -01434-17 ID# 53159 i I/19H