HomeMy WebLinkAbout06-08-2021 well & boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 3 8 5 5 6 0
WELL
OR BORING LOCATION WELL AND BORING SEALING RECORDCName Minnesota No.
Well No. H )
Minnesota Statutes,chapter 1031 or W-series No. y--.3 -..-,,
-.3 3 . G
.......
A Bane jr1L1
Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
urono 117 i., ub S2 S'It ti 6 . , ' c2r5aZ / 1/ - /o2 - :a 13
I'I GPS LOCATION-decimal degrees(to four decimal places) ..
Depth at Time of Sealing /,.."✓ ft. Original Depth l frr"' 9 ft. .
Latitude Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
ELL/BORING ❑Measured Date Measured ❑Estimated
U'+Li 4,axaview Parkway, Orono Water-Supply Well E Well
Show exact location of well or boring j 5 3k,4 Sketch map of well or boring Temp.Boring section grid with"X." location,showing property ❑other ft. ❑below ❑above land surface
lines,roads,and buildings. 1,
N CASING TYPE(S) •
- -----i
❑Steel ›i Plastic ❑Tile ❑Other
:--;--'-- I
- WELLHEAD COMPLETION '
W 1 ET
Outside:s Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
------ h Mile ❑Well Pit ❑Buried Well House
u' ❑
❑Well Pit
--- ----1- 1 -,,,....4). 1 - ❑Other
s 1
❑Buried
1-1 Mile I _,
t ❑Other
For temporary borings,provide additional lodat n CASING(S)
information,a site sketch,and geology on a se arate page.
Diamet r /++ Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME in.from (1) to ./.:"f..//2ft. ❑Yes /1 No ❑Yes ANo ❑Unknown
1 P L Landscape
Property owner's mailing address if different than well location address indicated above Li ❑ ❑ ❑ ❑Unknown
in.from to ft. Yes No Yes No
P.O. DO Y 1716 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
i urnvii1e, MA 55300 SCREEWOPENHOL7E
/ 7Q
WELL OWNER'S NAME/COMPANY NAME Screen from /c.7{e) to/u ! ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above XRods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) 7.`.r- _j
Obstructions removed? `hie Yes ❑No Describe
PUMP f^
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present IA`Pr�esent,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type ' sem. ` ,--6-^•-C-,-. -�.•
i (9 J,6 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE 1
sem✓ o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
/ rng 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 Flo TN# -
GROUTING MATERIAL(S) T�
,
Grouting Material/� 1-'� '.r,J "'`f{oj 1 �m �/ to . . ft. yards // 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 lY Jo 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.
uon 6todola well Drilling Co. , Inc. 16 -1
Licensee Business Name License or Registration No.
C- :.Re. -f e Signatur- ''"*- Certified Rep.No. Date
LOCAL COPY H 3 6 5 5 6 0 \, `"` 1/41:::3
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Name of Person Sealing Well or Boring-Tr.;
HE-01434-17 ID#53159 ' . S# 11nSR