HomeMy WebLinkAbout08-31-2021 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 8 8 4 9 4
WELL County OR BORING LOCATION Sealng No.
WELL AND BORING SEALING RECORD Name Minnlesota Unique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
Henne p S (Leave blank if not known)
Township Name+i[ Township No. Range No. Section No. Fraction(sm.--0 lg.) Date Sealed Date Well or Boring Constructed
Orono 118 23 27 S ; SW Sty 8/31/21
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 200 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location it Single Aquifer ❑Multiaquifer WELL/BORING k Measured Date Measured 8/31 lj
21 ❑Estimated
736 Dickey Lake Dr, Orono 5 3 6 Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring
in section grid with"X." location,showing property ❑Temp.Boring ❑Other 51 ft. r below ❑above land surface
lines,roads,and buildings.N CASING TYPE(S)
]Steel ❑Plastic ❑Tile ❑Other
y--- 4 f WELLHEAD COMPLETION
W E ',
' / Outside:J]Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'f t ` r` , ❑Well Pit ❑Buried ❑Well House
1
---,--- ---� *--- ❑Well Pit
./ 7_� ❑Other
s " . ❑Buried
1 Mile---� ,
❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. ts Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME in.from I to 96 ft. ❑Yes ❑No ❑Yes ❑No X Unknown '
Jim 'Jose h .
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
SCREEN/OPEN HOLE u� •
WELL OWNER'S NAME/COMPANY NAME Screen from 196 to 200 ft. Open Hole from to ft.
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? X Yes ❑No Describe
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
drift U OOIETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
r 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 [Nt No TN#
GROUTING MATERIAL(S)
Grouting Material Neat Cementfrom 1 to 200 ft. yards 15 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 X]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.
'ion Stodola Well Drillng Co INc 1691
Licensee Busines N e License or Registration No.
`" 558 8/31#J
21
rfif d
LOCAL COPY -f4epresentative Sign "re Certified Rep.No. Date
El383494 Jerry Barr
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R