HomeMy WebLinkAbout07-02-2021 Well and Boring Sealing Record ti , •
WELL OR BORING LOCATION-g. MINNESOTA DEPARTMENT OF HEALTH, Minnesota Well and Boring I„I' 387538
�8 7 5 3 8
-WELL AND BORING SEALING RECORD Sealing No. J(� Q
County Name ;,,•. - f-.' Minnesota Unique Well No.
• Minnesota Statutes,chapter 1031 orraW-serie. .s No.
.. iennepin .
Township Name Township No. Range No. Section No. Fraction(sm.•.Ig:) Date'Sealed Date Well or Boring Constructed
Orono 117 23'' 03 N Oi RW 'IN 01 712121 •
'GPS LOCATION-decimal degrees(to four decimal places)
•
Depth at Time of Sealing '"'• ft. Original Depth ft. --
Latitude Longitude •
-
AQUIFER(S) STATIC WATER LEVEL .
Numerical Street Address or Fire Number and City of Well or Boring Location jf Single Aquifer ❑.Multiaquifer • Z/2121
WELL/BORING X Measured Date Measur ❑Estimated
2250 Longview Crl, Orono X Water-Supply Well ❑Env.Well
Show exact location of well or.boring 553S6Sketch map of well or boring
in section grid with"X" location,showing property El temp.Boring • Iii Other ft. ❑below CI above land surface
lines,pQ ds -nd buildings.
N C' CASING TYPE(S) z-
' LernVt It 10
X Steel ❑Plastic ❑Tile ❑Other
---'--- --`--'--'`--- •• . WELLHEAD COMPLETION
W ET ktisf.,--
Outside: Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
Mile .0 Well Pit ❑
Buried• ❑Well House
1 r 1
D Pit
S - ❑Other '• ❑Buried
1 Mile---�. -- -•
^"❑Other -
x
For temporary.borings,provide additional to CASING(S)
information,a site sketch,and geology on a separate paw " "" Diameter 4 Depth.y Set in oversize hole? Annular space initially grouted?
PROPERTY�OWNE�R,'S NAME/COMPANYt � � NAME • 4 in.from 1 to 125 ft. ❑Yes ❑No ❑Yes ❑No Unknown
Pr eriy owners making�addressif Efferent than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEWOPEN HOLE
WELL OWNER'S NAME/COMPANY NAME WELL
from 125 to 1.29 ft.. Open Hole from to ft.
• OBSTRUCTIONS
, Well owner's mailing address if different than property owner's address indicated above jJ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction '
Type of Obstructions(Describe) droop Pipe
• Obstructions removed? Yes ❑No Describe .
PUMP ,
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing ❑Other
FORMATION ❑ G
If not known,indicate estimated formation log from nearby well or boring. Type`
drift 1 129 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE r
1 ®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) ��+r,�,�,,,,,..,, - r►
• _ Grouting Material Neat Cel!ent from 1 to 129 ft. yards 10 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 ®No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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. ,
Don Stodola Well Drilling Co. .Inc. 1691
• Licensee Business Name ,. License or Registration No.
•
-' ,, 2691 . .
9"�resentative`Signature i' Certified Rep.No. Date
s
Y
LOCAL COPY • H 3875 3 8 Jerry Barr
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 , 11/1913