HomeMy WebLinkAbout12-13-2021 Well & Boring Sealing RecordHE -01434-17 ID# 53159 a isn
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No.
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, chapter 1031 r W_SeerieswNo.
HWELL 392191
OR BORING LOCATION
County Name i
+
enne in
Township Name
Township No.
Range No.
Section No.
Fraction (sm. -r Ig.)
Date Sealed
Date Well or Boring Constructed
zona
117
23
07
,ANN ESN
140 12/13/21
GPS LOCATION — decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing 140 ft.
Original Depth ft.
AQUIFER(S)
[NSingle Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
1 *f / f / �f •
1
Measured Date Measured i G i 1. ❑ Estimated
7 ft. �] below E] above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
94CF, North Arm Dr, Orono
WELUBORING
[?FWater-Supply Well ❑Env. Well
El Temp. Boring ❑ Other
Show exact location of well or boring Sketch map of well or bating
in section grid with "X" location, showing property
N lines, roads, and buildings.
y
CA$INGTYPE(S)
❑Steel Cyt � Plastic E] Tile ❑ Other
I l I l
W t l e ' i5P
'k Mile r .
r 1
I I I I o�
S
�1 Mile
WELLHEAD COMPLETION
Outside: Xj Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
❑ Well Pit ❑ Buried Well House
o Well Pit
El Other
❑ Burled
❑ Other
For temporary borings, provide additional location
CASING(S)
information, a site sketch, and geology on a separate page.
Diap+eter 1 Depth Set in oversize hole? Annular space initially grouted?
't In. from to 130 ft. ❑ Yes ❑ No ❑ Yes ❑ No A Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
P OPER OWNE ' NAMEICOMPAN ME
Zander Romes �(ZVNnAe.V
Property owners mailing address if different than well location address indicated above
10300 10th Ave No
Plymouth, MN 55441
in. from to h. ❑Yes ❑ No El Yes ❑ No El Unknown
SCREEWOPEN HOLE
Screen from 130 to 140 R. Open Hole from
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ FIII No Obstruction
Well owner's mailing address 9 different than property owners address indicated above
Type of Obstructions (Describe)
Obstructions removed? ❑ Yes ❑ No Describe
PUMP
Not Present ❑ Present, Removed Prior to Sealing Other
g ❑
-
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
drift
0
1 4
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremfe 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)
�+ n
Grouting Material Neat Cement from 1 to 140 ft. yards l2 bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
yy
Other unsealed and unused well or boring on property? E] Yes L1 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 3todola, Well Drilling Co Inc 1691
Licensee Business N e License or Registration No.
558 12/1.3/21
entified Repiesentaffve Signatu a Certified Rep. No. Date
Jury Bahr
LOCAL COPY
H I ;? ,I
Name of Person Sealing Well or Boring
HE -01434-17 ID# 53159 a isn