HomeMy WebLinkAbout06-08-2022 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ')0 1 0 2
Sealin No.County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
,- Minnesota Statutes,chapter 103I or W-series No.
TTennep 3 (Leave lank if not known)
n
Taliyffship Name ' Township No. Range No. Section No. Fraction(sm.-*lg.) Date Sealed Date Well or Boring Constructed
Orono 117 23 20 NW 6/8/22
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 53 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ►'Single Aquifer ❑Multiaquifer 80 Garment St O� 5 C 393 WELL/BORING Z Measured Date Measured ! ❑Estimated
2�# ] 'T L X Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring 7 ft.❑Temp.Boring ❑Other below ❑above land surface
in section grid with"X." _ location,showing property
N lines,roads,and buildings. CASING TYPE(S)
Steel ❑Plastic ❑Tile ❑Other
j 77
f's WELLHEAD COMPLETION
W E '�'.°"'e, ,"-+-,"a--+.,.�,r�-.---- ,.., -...-�.�,
T Outside: [ Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'h Mile d ❑Well Pit ❑Buried ❑Well House
1 I i , ❑Other
❑Well Pit
t
3 ❑Buried
I1 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?
4Fti0I RTY OvIF�R S AaMIc O ANY NA E 4 in.from I to 49�" ft. ❑Yes ❑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
70 Florence Dr .
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Excelsior, NN 55331
SCREEN/OPEN HOLE q
Screen from "` "to 3 ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
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
Type of Obstructions(Describe) Drop Pipe
Obstructions removed? ]Yes ❑No Describe
PUMP
-. GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO ❑Not Present Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type submersible
drift 0 53 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
M 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 X No TN#
GROUTING MATERIAL(S)Grouting Material Neat Gee n t from 1 to 53 ft. yards 5 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 Drilling Co Inc 1691
Licensee Business Name License or Registration No.
�� ►
558
r
erti epr�esentativeignatuie Certified Rep.No. Date
LOCAL COPY
" 3 9 5 1 0 2 Jerry Barr
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R