HomeMy WebLinkAboutwell and boring sealing record 3 BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H o. 4 0 5 8 7 9
me WELL AND BORING SEALING RECORD MinSeanesota Na Unique Well No.
NEPIN Minnesota Statutes,chapter 103i or W-series No.
(Leave dank it not known)
lame Township No. Range No. Section No. Fraction(sm.-a lg.) Date Sealed Date Well or Boring Constructed
MO 117 23 05 NFINESE ,k11/21/23
\TION—decimal degrees(to four decimal places)
1
Depth at Time of Sealing 16 ft. Original Depth ft.
Longitude
AQUIFER(S) STATIC WATER LEVEL
Street Address or Fire Number and City of Well or Boring Location IR Single Aquifer ❑Multiaquifer 1`/ZZ/Z�
WELL/BORING Measured Date Measured ❑Estimated
OXFORD ST.,ORONO, MN. 55356
[,Water-Supply Well ❑Env.Well
t location of well or boring Sketch map of well or boring ,,--77rr''
)rid with"X." location,showing property ❑Temp.Boring ❑Other 8 ft. Ai, ❑above land surface
line,roads,and buildings.N CASING TYPE(S)
rl 1, IDSteel IrPlastic IIITile ❑Other
X WELLHEAD COMPLETION
E �.. f�
r T k. Outside: p Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
h MAll !`i ❑Well Pit ❑Buried ❑Well House
T II T_* 0 4::::)
❑Well Pit
. 1
9
❑Buried
—1 Mile I
❑Other
rary borings,provide additional location 1
❑Other CASING(S)
t,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially'grouted?
yrOWhIE RreMf/COMPANY NAME 4 in.from 1 to 106 ft. El Yes 0 No ❑Yes ❑No ❑Unknown
ner's mailing address if different than well location address indicated above in.from to (t. ❑Yes ❑No ❑Yes ❑No ❑Unknown
'in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown
SCREEN/OPEN HOLE
W-. Screen from 106 to 116 ft. Open Hole from to ft.
JER'S NAME/COMPANY NAME 7 !�
REAL&ESTATE I.1.0 OBSTRUCTIONS
mailing address if different than property owner's address indicated above [!ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
5 FOX STREET Type of Obstructions(Describe) drop pipe
NO, MN. 55356
Obstructions removed? M Yes ❑No Describe
PUMP
HARDNESS OR
3ICAL MATERIAL" COLOR FORMATION FROM TO ❑Not Present (Present,Removed Prior to Sealing ❑Other
in,indicate estimated formation log from nearby well or boring. rsibl*
i Type
ft 1 116 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
AIL 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 XNo TN#
GROUTING MATERIAL(S) 9
Grouting Material Neat Cement from 1 to 116ft. yards bags
9
from _ to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes Z No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
i,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 Busin s Na a '' License or Registration No.
11/22/23
e edt-representative Signature Certified Rep.No. Date
LOCAL COPY H 4 0 5 8 7 9 Jerry Barr
Name of Person Sealing Well or Boring
17 ID#53159 ili19R