HomeMy WebLinkAboutUntitled MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H I 4 8
0 5 8
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. V 8
County Name Minnesota Unique Well No.
l E N N£PIN Minnesota Statutes,chapter 1031 or W-series No.
(Leave dank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed
ORONO 117 23 07 IENESE '. 11/27/23
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 85 ft. Original Depth ft.
Latitude Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location 4 Single Aquifer ❑Multiaquifer
1301 NORTH ARM OR. ,MOUND,MN • WELL/BORING ®Measured Date Measured 11/27/23 ❑Estimated
f Water-Supply Well ❑Env.Well 71
Show exact location of well or boring 5536 ketch map of well or .ring
in section grid with"X." location,showing prop:ty ❑Temp.Boring ❑Other ft. ®below ❑above land surface
N in-s, and buildin s. CASING TYPE(S)
r4.)
die_ [Steel ❑Plastic ❑Tile ❑Other
F
---'------
'---•--`------
`--- WELLHEAD COMPLETION
W E
T
r
a utside: x Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
'h Mile Z.. ❑Well Pit ❑Buried ❑Well House
---, r- —.1
1
iii X 7-
❑Other ❑Well Pit
s ❑Buried
1 Mile g,�
hu ❑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?
PROPERTY OWNER'S NAME/COMPANY NAME A in.from 1 to 8 1 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown
SABRINA VLECY
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 fi
WELL OWNER'S NAME/COMPANY NAME Screen from _81 to 8 5 ft. Open Hole from to ft.
SABRJ A VLEC1 OBSTRUCTIONS
Well owner's mailing address if different than properly owner's address indicated above jRods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) DROP PIPE
Obstructions removed? QYes ❑No Describe
PUMP .
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present jj Present,Removed Prior to Sealing❑ u ❑Other
If not known,indicate estimated formation log from nearby well or boring. C Type SUBMERSIBLE
DRIFT 1 85 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
k 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 ANo TN#
GROUTING MATERIAL(S)
NEAT CEMENT 1 85 8
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.
558 1I/27/23
erti Representative Signature Certified Rep.No. Date te
LOCAL COPY ' H. 405888 JERRY BARR
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R