HomeMy WebLinkAbout10-27-2022 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALT N n 6 /Minnesota Well and Boring 39�J Q
WELL OR BORING LOCATION Sealing No. J.
1 4 2
County Name WELL AND BORING SEALING RE ORDA H Minnesota Unique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
Hennepin (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-+lg.) Date Sealed Date Well or Boring Constructed
Orono 117 23 05 SWA SW SW 10/27/22
GPS LOCATION—decimal degrees(to four decimal places) 1 T 05
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 A Single Aquifer ❑Multiaquifer 10/27/22
y90 To� $wa �d � WELL/BORING [ Measured Date Measured El Estimated
7 4 Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring 68
in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. ®below ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
* °Steel ❑Plastic ❑Tile ❑Other
* LLHEAD COMPLETION
W e, f
T Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset
f �-
1'k miiel, • ❑Well Pit ❑Buried ❑Well House
- 1 I .- ❑Well Pit
s ❑Other
❑Buried
I —1 Mile {
' , ❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. Diameter Dept t� Set in oversize hole? Annular space initially grouted?
P RTY O WNS NA OMPANY NAME 3 in.from to V 1 ft. ❑Yes ❑No ❑Yes ❑No A Unknown
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 ❑No ❑Yes ❑No ❑Unknown
SCREEWOPEN HOLE
101 105
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 ❑No Obstruction
DRO PIPE
Type of Obstructions(Describe)
Obstructions removed? �► Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION a�
❑Not Present Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type S la.iL E . ItLE
DRIFT 1 105 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE i
2.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)
Grouting Material NEAT CEMENT from 1 to 105 ft. yards 5 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? ❑Yes [I 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 Dri 11 ing Co 11191
Licensee Business Name License or Registration No.
(,/-"
� .. 558 10/27/22
certified Re resentative Signature Certified Rep.No. Date
JERKY ARLi
LOCAL COPY H 3 9 81. 4 2 Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R