HomeMy WebLinkAboutwell & boring sealing recordWELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSeal411629
emepin WELL AND BORING SEALING RECORD Minnte9otaoUnique Well No. ,
Minnesota Statutes, chapter 1031 or W-series No.
(tame dank a rwt kmxn)
TmqkDame jTownl"o. R2ge No, Se6lon No. acligt (srrNV Ig.) Date Sealed 8/13/2024 Date Well or Boring ConstgMA/1979
'/ ,/4
GPS LOCATIC 94fty2Idegrees (to four decimal pl-a§l639947 125 125
Latitude Longitude Depth at Time of Sealing ft. Original Depth ft.
QUIFER(S) STATIC WATER LEVEL
"3rW ArpH "4€MsLoARE OR (fit 84Boring location Single Aquifer ❑ Multiaquifer 8/13/24
WELL/BORING Measured Date Measured ❑Estimated
Water -Supply Well El Env. Well 73
Show exact location of well or boring Sketch map of well or boring
in section grid with "X" location, showing property ❑Temp, Boring El Other ft. 1G�1 below ❑above land surface
N lines, roads, and buildings. CASING TYPE(S)
w
t
E
Steel ❑ Plastic ❑ Tile ❑ Other
f WELLHEAD COMPLETION
T
Outside:x Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
'h Mile ❑ Well Pit ❑ Buried ElWell House
)> ❑ Other ❑ Well Pit
s a ❑ Buried
i1 Mile ❑ Other
For temporary borings, provide additional location ,'' 1eA i CASING(S)
information, a site sketch, and geology on a separate page. Diameter 0 DepT21 `� Set in oversize hole? Annular space initially
grouted?
Yd55FF nW I f IVAME/COMPANY NAME in. from to ft. P Yes ❑ No ❑ Yes ❑ No yJ Unknown
Pro er owner's mailing address if different than well location address indicated above in. from to ft. [I Yes ❑ No ❑ Yes ❑ No f 1❑ Unknown
215 forth Arm Lane
Orono Mn 55364 in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN fjQL1E 125
18FhIdW&RCS" FiS9yPANY NAME Screen from to ft. Open Hole from to ft.
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill] No Obstruction
2536 -18th Ave S
Minneapolis, MN 55404 Type of Obstructions (Describe)
Obstructions removed? ❑ Yes ❑ No Describe
PUMP XXXX
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑ Not Present Present, Removed Prior to Sealing ❑ Other
Subme sible
If not known, indicate estimated formation log from nearby well or boring. Type
JaETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
Clay Yellow 72� .9--No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
sing Diameter
Clay B Ue 19 00 in. from to ft. ❑ Perforated ❑ Removed
n. from to ft. ❑ Perforated ❑ Removed
Sand ruw[I 112 125 Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑ No TN#
GROUTING MATERIAL(S)
_ I Neat Cement 0 125 10
Grouting Material from to ft. yards bags
from to ft, yards bags
from to ft. yards bags
KOM moo ant OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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
ELEVATION: 968FT is true to the best of my knowledge.
E.H. Renner & Sons, Inc. 1431
Licensee B in s Name License or Registration No.
tj Iry / hj8/19/2024
GEOLOGY FROM ORIGINAL WELL RECORD
Certified Re resentative Signature Certified Rep. No, Date
ED RENNFIR / NICK ANDERSON
LOCAL COPY H 411629 Name of Person Sealing Well or Boring
HE-01434-17 ID# 53159 11/19R