HomeMy WebLinkAbout05-24-2023 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H401694
County Name No.
WELL AND BORING SEALING RECORD MinnSealesota Unique Well No.
liENNEPIN Minnesota Statutes,chapter 1031 or W-series No.
(Leave blank if.known)
Township Name Township No. Range No. Section No. Fraction(sm..—+lg.) Date Sealed Date Well or Boring Constructed
ORONO 117 23 17 tW WSE lk 5/24/23
-
I GPS LOCATION—decimal degrees(to four decimal places) 226
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 I]Single Aquifer ❑Multiaquifer 5/2 4 2 3
2171 #�ADYWOOD r ear WELL/BORING Measured Date Measured ❑Estimated
AsiA• '
- ]Water-Supply Well ❑Env.Well
Show exact location of well or boring 5.5391 Sketch map of well or boring 40
in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. ,XA below ❑above land surface
lines,roads,and buildings.
N CASING TYPE(S)
NSs
Steel ❑Plastic ❑Tile ❑Other
---'-- WELLHEAD COMPLETION
W —.E
T ii.,,
Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: g Basement Offset
h Mile ❑Well Pit ❑Buried ❑Well House
' S-r r-
- ❑Well Pit
❑Other
❑Buried
1 Mile
❑Other
For temporary borings,provide additional loca . CASING(S)
information,a site sketch,and geology on a se..ate'' . Di eter De h. Set in oversize hole? Annular space initially grouted?
P PERTY OWNER' ME COMPANY NAME in.from 1 to ft.� A ii i`iSt i ❑Yes ❑No ❑Yes ❑No ]Unknown
Property owner's mailing address if different than wel - ion address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEWOPEN HOLE
226
Screen from "�" to ft. Open Hole from to ft.
• WELL OWNER'S NAME/COMPANY NAME '
JACQUELIN ROBERTSON OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above Fl Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
. DROP PIPE
Type of Obstructions(Describe)
Obstructions removed? ❑Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present g Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. ey Type JET PUE4P
' 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? ❑Yes ]No TN#
GROUTING MATERIAL(S)
NAT CE E r 1 226 5
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.
DON STODOLA WELL DRILLING CO. ,iNC. 1691
Licensee Business Name License or Registration No. '
� p 55 5/24/23
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY H 401 0 04 J E R Y B A R
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R