HomeMy WebLinkAboutwell and boring sealing record WELL OR BORING LOCATION itINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 4 0 7 7 7 4
County Name — WELL AND BORINGSEALING RECORD Min nleso aoUnique Well No.
HHENNEPIN Minnesota Statut , lhapter 1037 or W-series No.
l--,.: (Leave dank M not known)
Township Name Township No. Range No. Section No. Fr&ction(sm.—.lg.) Da ealed Date Well or Boring Constructed
ORONO 117 23 17 IIWAIS SEk 2/28/2024
GPS LOCATION—decimal degrees(to four decimal places)
Deoth at Time of Sealing 243 ft. Original Depth _ _ ft.
Latitude Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ]Single Aquifer ❑Multiaquifer 2/28/2024'
WE Estimated
2232 SLIADYWOOD RD. ,WAYZATA,MN LL/BORING �Measured Date Measured
3�; �]Water-Supply Well ❑Env.Well 44
Show exact location of well or boring Sketch map of well or boring
in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. A below ❑above land surface
N lines,roads,and buildings. CP6INGTYPE(S)
a.
SEI Steel ❑Plastic ❑Tile ❑Other
_----"" ` "' WELLHEAD COMPLETION
W ET
• Outside: k]Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
- - 1mile ❑Well Pit ❑Buried ❑Well House
---•------- ❑Well Pit '
r s y-1 ❑Other
❑Buried
I I Mile 1k Othe
❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and.eology on a separate)' Diameter Depth 3 5 Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME in.from1 to ft. ❑Yes ❑No ❑Yes ❑No in Unknown
SCkiERBER CO
Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
4!
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEWOPEN HOLE
Screen from235 to 243 ft. Open Hole from to ft.
L O ER'S NAME/COMPANY NAME
C E MjDDEN'DORF OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above C]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
DROP` PIPE
Type of Obstructions(Describe)
Obstructions removed? I Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Notc+Pr�etsent D®+*Present�pRemoved Prior to Sealing ['Other
If not
known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE
DRIFT I r T 1 243 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)
GroutingMaterial NEAT CEMENT„, 1 to 243 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 I 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 N e License or Registration No.
558 2/28/2024
rtiif Representah''e S�rur Certified Rep.No. Date
�� 9 P
LOCAL COPY H 4 0 7 7 7 4 JERRY BARR
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 wise
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