HomeMy WebLinkAbout09-26-22 well and boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringW Hng No. e p
CountyELL OR BORING LOCATION SealWELL AND BORING SEALING RECORD Name Minntesota Unique Well No. �?
Minnesota Statutes,chapter 1031 oBBW series No.
AtihitaINve blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed
CRUNO 118 23 25 S'i 3 SEA 9/26/22
GPS LOCATION-decimal degrees(to four decimal places) Depth at Time of Sealing 354
. ft. Original Depth ft.
Latitude Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire
�+Number
RD. ,and City of Well or Boring Location ®Single Aquifer III Multiaquifer
J25 liOLLANDER Oeiur O, AA WELL/BORING ®Measured Date Measured 9/26/22 ❑Estimated
r Water-Supply Well ❑Env.Well
Show exact location of well or boring 53391 Sketch map of well or boring
in section grid with"X." location,showing property ❑Temp.Boring ❑Other 154 ft. ®below ❑above land surface
lines,roads,and buildings.
N a r CASING TYPE(S)
j]Steel ❑Plastic ❑Tile ❑Other
"-"' T WELLHEAD COMPLETION
W E I
Outside: ®Pitless Adapter/Unit III At Grade Inside: Ill Basement Offset
Mile -. ❑Well Pit ❑Buried ❑Well House
- (.
❑Other ❑Well Pit
S ❑Buried
1 Mile ❑Other
For temporary borings,provide additional location CA NG(
information,a site sketch,and geology on a separat 3 Dia Depth Set in oversize hole? Annular space initially grouted?
PRCrI L QVy kR'S NA.ME 9APANY NAME . in.from to ft. LI Yes El No ❑Yes IA No ®Unknown
Property owner's mailing address if differentr than well locatio in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from ,to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEWOPEN HOLE
WELLtaOWN�ER'S_NAME/COMPPANYiNAME wI+q� �+ a,S=t a ty�« Screen from to ft. Open Hole from to ft.
JEROME & CHARLOTTE GOLINVAUX OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill t No Obstruction
325 HOLLAN HER RD. Type of Obstructions(Describe)
ORONO, t N 55391
Obstructions removed? ❑Yes ❑No Describe
�'
'. -PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing
FORMATION ® ❑ III Other
I If not known,indicate estimated formation log from nearby well or boring. 354
C g Type
-'x }-L i' 354
1 1 ,MyE�THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
IA 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 --- NEAT CE :ENT 1 354 40
Grouting Material from 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 ❑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. CO
1692.
Licensee Business Name License or Registration No.
edified Representative Signature Certified Rep.No. Date
JL.ftAi DAM(
LOCAL COPY H 3 9 6 9 8 8 Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 ti/tsR