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HomeMy WebLinkAbout12-23-2021 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3921 6 2 SealCounty Name WELL AND BORING SEALING RECORD Minnlesotang oUnique Well No. Hennepin Minnesota Statutes,chapter 1031 or W-series No. (Leave dank I/not known) Township Name Township No. Range No. Section No. Fraction(sm.-a Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 21 SW #W 41W 12/23/21 GPS LOCATION—decimal degrees(to four decimal places) Depth at Time of Sealing 64 ft. Original Depth ft. Latitude Longitude laUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer Pheasant ) l 2670 haSt Rd ©rOAQN WELL/BORING X Measured Date Measured 12/ 23!21 IIIEstimated I Water-Supply Well ❑Env.Well Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property ❑Temp.Boring ❑Other ft. X below ❑above land surface lines,naiads, . ads,,nd buildin. N CASING TYPE(S) 111111111111 y( Steel Plastic ❑Tile ❑Other ��wmkf �Ytt WELLHEAD COMPLETION INIENIWT. � Outside: ID Pitless Adapter/Unit ❑At Grade Inside: lk Basement Offset I Mile ❑Well Pit III Buried ❑Well House 111111111011 1 ❑Other ❑Well Pit S Buried I Hulk ❑Other_ For temporary borings,provide additional location CASING(S) information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from to _ft. ❑Yes ❑No ❑Yes ❑No IC Unknown RJ Nalene Construction Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 4464 West Ara Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Sprin6 Park, MR 55384 SCREEWOPEN HOLE WELL OWNER'S NAME/COMPANY NAME Screen from 60 to 64 ft. Open Hole from to ft. OBSTRUCTIONS Well owner's mailing address if different than property owner's address indicated above IC Rods/Drop Pipe ❑Check Valve(s) ❑ss Debris ElFill ❑No Obstruction Type of Obstructions(Describe) drop pipe Obstructions removed? [)Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO FORMATION ❑Not Present X Present,Removed Prior to Sealing ❑Other If not known,indicate estimated formation log from nearby well or boring. Type subme r a I b 1 e drift 0 64 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE LNo 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 X]No TN# GROUTING MATERIAL(S) Grouting Material_ eat Cement from 1 to b4 ft. yards 5 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 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 I is true to the best of my knowledge. gt DON STODOLA WELL DRILLING CO., INC• 1�■A Licensee Busin Name License or Registration No. —"" ' 441 l-�r 558 12/23/2 if Representative Signature Certified Rep.No. Date LOCAL COPY v H 92162 Jerry parr Name of Person Sealing Well or Boring HE-01434-17 ID#53159 17naR WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 9 21 6 County Name WELL AND BORING SEALING RECORD M SealingNo. Well No. Hennepin Minnesota Statutes,chapter 1031 or W-series No. (Leave dank H not known) Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 21 SHAME VW 12/23/21 GPS LOCATION-decimal degrees(to four decimal places) tt Depth at Time of Sealing 63 ft. Original Depth ft. Latitude Longitude AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ❑isingle Aquifer ❑Multiaquifer 1 2670 Pheasant Rd Orono, Moa WELL/BORING X Measured Date Measured 1 21 ❑Estimated I Water-Supply Well ❑Env.Well Show exact location of well or boring Sketch mapi,of well or borin. 17 x in section grid with"X." location,shi.wing propert ❑Temp.Boring ❑Other ft. rJ below ❑above land surface lir,r ad6,-and bu'.',.s. N ;, - CASING TYPE(S) .- �` �)i" I Steel ❑Plastic ❑Tile Li Other - t---------------- -.- e WELLHEAD COMPLETION w E Outside: ❑Pitless Adapter/Unit El At Grade Inside: I Basement Offset 'h Miledill6 El Well Pit ❑Buried ElWell House -- -r - -- 1 ❑Other ❑Well Pit S 0 Buried 1----t Mile El Other . For temporary borings,provide additional location CASING(S) information,a site sketch,and geology on a separate page. Diater 1 Depte Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No X Unknown kJ Yaiek Construction Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes El No ❑Yes 0 No ❑Unknown 4464 West Arm Rd Spria Park, MN SCREENroPENHOLE WELL OWNER'S NAME/COMPANY NAME Screen from to 63 ft. Open Hole from to ft. 55384 OBSTRUCTIONS Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) I Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) dirt gravel Obstructions removed? ❑Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO I Not Present ❑Present,Removed Prior to Sealing ❑Other FORMATION Iffnot jknown,indicate estimated formation log from nearby well or boring. j� Type drift 0 63 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE FNo 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 IN No TN# GROUTING MATERIAL(S) h Grouting Material Neat Cement from to 63 tyards 3 bags 9 _ from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? El Yes X 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. DOA STODOLA WELL DRILLING CO., INC. 1691 Licensee Business Name or Registration No. / ssa 12/28/2 C ted epresentative Signature Certified Rep.No. Date LOCAL COPY H 3 9 216 9 Jerry Barr Name of Person Sealing Well or Boring HE-01434-17 ID#53159 11/19f