HomeMy WebLinkAbout12-29-2022 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H399130
SCounty Name - WELL AND BORING SEALING RECORD Min nle otaoUnique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
ALANE?iN (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-,lg.) Date Sealed Date Well or Boring Constructed
O O O 116 23 35 3E5oE ' ,A 12/2 /Z2
GPS LOCATION-decimal degrees(to four decimal places) 83
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 X.Single Aquifer ❑Multiaquifer 12129/22
1225 RO UA S tl . , OR t „ ,ji WELL/BORING X Measured Date Measured �r +Gr ❑Estimated
V �l 6+ &J rWater-Supply Well ❑Env.Well
Show exact location of well or boringSketch mapof well or boring
in section grid with"X." location,showing property ❑Temp.Boring ID +Other 1 ft. X below ❑above land surface
N a..,), liries,rgads,and,,buildings.
CASING TYPE(S)
__
❑X Steel ❑Plastic ❑Tile ❑Other
WELLHEAD COMPLETION
W • E
T Outside:X Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'k Mile ❑Well Pit ❑Buried ❑Well House
s 1Well Pit
❑ i
❑Other
❑Buried
I 1 Mile
❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. . Diame,)er Depth ft. Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from to 7
C R I S di EP A N I E I SSON
❑Yes [I No ❑Yes ❑No Unknown
Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1225 ORONO OAKS D
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
cORONO, MN. 55356SCREEWOPEN HOLE
WELL OWNER'S NAME/COMPANY NAME Screen from 79 to 83 ft. Open Hole from to ft.
CL IS 4 STEPHANIE £RIKSr ON OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) drop pipe
Obstructions removed? XYes ❑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 submersible
drift 0 83 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
X 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 It No TN#
GROUTING MATERIAL(S) Cement
Grouting Material Neat from 1 to 1.1 3 ft. yards 9 bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on pperty? ❑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.
DUB 3TOD Ak W LL DRILLING CO. ,I L. 1691
Licensee Business Name ,,, License or Registration No.
'-:3-ei"," - / 12/29/22
Certified Represen alive Signature Certified Rep.No. Date
Jerry Barr
LOCAL COPY H 399130 Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R