HomeMy WebLinkAbout04/23/21 Well & Boring Sealing RecordWELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
County Name WELL'AND BORING SEALING RECORD nnl
ng No.
Mieso a Ulruque Well No.
Minnesota Statutes, chapter 1037 orreW seriees,�N°I
TT �iM
H 389.624
Township Name
Township No.
Range No.
Section No.
Fraction (sm. -+ Ig.)
Date Sealed
Date Well or Boring Constructed
HMS fO
j1'_7_-
23
04
I 7? W,4 Nig
4/2 2
GPS LOCATION - decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing 122 ft.
Original Depth ft,
AQUIFER(S)
Single Aquifer ❑ Mutilaquffer
STATIC WATER LEVEL
Measured Date Measured 4123121 [1 Estimated
73 ft. DC below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
5 Watertown Road OronoWater-Supply
WELL/BORING
Well ❑ Env. Well
❑ Temp. Boring ❑ Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X" location, showing property
N �r� rt'lines, roads, and bpildings.
CASINGTYPE(S)
jjj}}}y
[X Steel ❑ Plastic ❑ Tile ❑ Other
------ i
1
W 1 I E T
i s - ---1-- I
'b Mlle
--�--- --T-- --%-- ------
,1
s t y
—t Mlles
WELLHEAD COMPLETION
Outside: Pitiless Adapter/Unit El At Grade Inside: ❑Basement Offset
`
❑ Well Pit ❑ Buried ❑ Well House
El Well Pit '
❑ Other
❑Buried
❑ 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 spade initially grouted?
4 in. from 1 to 106 ft. ❑ Yes ❑ No ❑ Yes ❑ No Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Retfi Trautman
Property owner's mailing address if different than well location address indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
Screen from 108 to ft. Open Hole from to ft.
WELL OWNER'S NAMEICOMPANY NAME
OBSTRUCTIONS
[ItRodstDrop Pipe ❑Check Valve(s) El Debris El Fill ❑ No Obstruction
i
Well owner's mailing address if different than property owner's address indicated above
Type of Obstructions (Describe) drop pie—
Obstructions removed? N Yes ❑ No Describe
PUMP
El Not Present tX Present, Removed Prior to Sealing ❑ Other
Type suhMPrSihl0
GEOLOGICAL MATERIAL COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimat ormation log from nearby well or boring.
T)ri ft
1
112METHOD
USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
[XNo Annular Space Exists ❑ Annular Space Grouted with Tremfe 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 MORt CA-MA�[tt from 1 to 112 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 t,4 No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
is true to the best of my knowledge.
Ian Stodola Well Drillin- Co Inc 1691
Licensee Business Name License or Registration No.
4123/21
r se tafive Si iisf re Certified Rep. No. Date
CV rarC
LOCAL COPY
H �r 8 16 4
Name o/ arson Sealing Well or Bating
HE -01434-17 ID# 53159 11/79A