HomeMy WebLinkAboutWell and boring sealing record FH of 405089
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL OR BORING LOCATION Seating•No. H
County Name WELL AND BORING SEALING RECORD Mlnnesota Unique Well No.
Minnesota StatutesBenne in ,chapter 1031 or W-series No.
..�.(Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed f ,,,� 1 ;,..,.. Date Well or Boring Constructed `
Orono 117 23 09 • X-W S'ti / `-' ',- `'. �,_-
GPS LOCATION-decimal degrees(to four decimal places) r'""'{ '
Depth at Time of Sealing ft. Original Depth ft. •
Latitude Longitude -
NUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ASingle Aquifer'❑Multiaquifer An
/ #// . 74,
North. Shore- Orono WELLBOSING ISI Measured Date Measured d ❑Estimated
3105
Drive
❑Water-Supply Well E Well // �R
Show exact location of well or boring Sketch map of well or boring
in section grid with"X." 2 1 location,showing property ❑Temp.Boring ❑Other La') ft. .below ❑above land surface
55391 lines,roads,an. •uildings. ,
N CASING TYPE(S)
q1 Steel
❑Plastic ❑Tile ❑Other ,,
-.---'---- iil !!!!llWEELLHEAD COMPLETION
r__ r__- Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset /
Mile ❑Well Pit ❑Buried ❑Well House
❑Other
❑Well Pit
S # i s
1, ❑Buried
�£.ya I 1 Mile— I - :` r
( L'" ❑Other
-For temporary borings,provide additional location i II..., • CASING(S)
''
information,a site sketch,and geology on a separate page. - Drier Dept, ..!ly, ,,,,,, Set in oversize hole? Annular space initial) grouted?
PROPERTY OWNER'S NAME/}COMPANY NAME in.from / to e > Elft. ❑Yes ❑No ❑Yes No Unknowny
Wood4 lie Rtti i€tprc1 Inc_ .
Property owner's mailing address if different than well location address indic fed above in.from to f ft. -Y . ❑Yes ❑No ❑Yes ,,, ❑No ❑Unknown '
•
6117 Blue Circle Drive .
• #1 0# in.from to ft. ❑Yes ❑No ❑Yes Q No ❑Unknown
Minnetouka,Mn. 55343 SCREEN/OPENHOLE
WELL OWNER'S NAME/COMPANY NAME Screen from ... to ft. -Open Hole from to ft. .3
OBSTRUCTI.. { i_:,:-^ , _` _ 1I.
_ Well owner's mailing address if different than property owner's address indicated above • XRod-Drop Pipe ❑Check Valve(s) ❑Debris '❑Fill .❑No Obstruction
Type of Obstructions(Describe)ri► -
Obstructions removed? Ji4.Yes ❑No Describe I
PUMP
HARDNESS OR
GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Not Present Presents.Remo ed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or, QCing. Type• 1 . +++���111(5 F
. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
XNo 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) �j' ''.. '
Grouting Material/)e f /1 ('13 / to q ft. . yards O bags
I 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.
�r! ma�qy, r�a p��y sA WELL DRILLING ��ss INC h•�i
r- Licensee Business. ame License or Registration No.
y r 558 /).//
rtif edl 'Representative Signature Certified Rep.No. Date
LOCAL H _4:0 5 Q 8 9w r �: - el ter
" Name of Person Sealing Well or Er .
HE-01434-17 ID#53159 • -
11/19R