HomeMy WebLinkAbout07-20-2022 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �]
County Name WELL AND BORING SEALING RECORD
MinnlesotaeUnique Well No. p
y� Minnesota Statutes,chapter 1031 or W-series No.avelank if not known)
Re n it e p i (Le b
Township Name Township No. Range No. Section No. Fraction(sm.—'lg.) Date_Sealed Date Well or Boring Constructed
Orono 117 23 041 NIeNg St4 130 7/20/22 7/20/22
GPS LOCATION—decimal degrees(to four decimal places) 130
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 rA Single Aquifer ❑Multiaquifer # e�
Lakeview
Pkwy� Orono
���� WELL/BORING Measured Date Measured 30 l ® timated
610 ®Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring Temp. 130
BoringOther ft.
in section grid with"X." location,showing property ❑ ❑ IC below ❑above land surface
N lines,roads,and bldings. CASING TYPE(S)
I
-+� f" ITO CASING
❑Steel ❑Plastic ❑Tile ❑Other
ez
-
--`------`--- �,' WELLHEAD COMPLETION
w 1 E F �
_ T Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
.. .,,,mow I
2 r
} ❑Well Pit ❑Buried ❑Well House
*--
__ i '7.: ❑Other ❑Well.Pit
S ,,,,,,,. ❑Buried
I 1 Mile -
❑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 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Norton Roses
,Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
45th in.from to ft. El Yes ❑No ❑Yes ❑No ❑Unknown
r Plymouth, MN 55446
SCREEN/OPEN HOLE
WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill IENo Obstruction
Type of Obstructions(Describe)
Obstructions removed? ❑Yes ❑No Describe
y:: PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION Not Present ❑Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
❑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? ❑Ye XI No TN#
GROUTING MATERIAL(S)
Neat Cement
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.
Bad Role NO CASINGGrouted Role Don Stodola Well Drillin 8 Co Inc 1691
Licensee Business Name License or Registration No.
55 7/20/22
Certified Representative Signureat Certified Rep.No. Date
�a, Jerry Barr
LOCAL COPY H ,: Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R