HomeMy WebLinkAboutWell Sealing Record 2-25-25'r• MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 415603
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD . Sealing Nounique Well No.
County Name
r HENNEPIN Minnesota Statutes,chapter 1031 oraW seriesNoo.
Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed
ORONO 118 23 27 S6diS 'a SF 2/2'SI C}25 .
GPS LOCATION-decimal degrees(to four decimal places)Latitude Longitude 4
Depth at lime of Sealing 1 2 7 ft. Original Depth ft.
AQUIFER(S) STATIC WATER LEVEL `
Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer ❑Multiaquifer
900 BROWN RD,N.. ,LONG LAKE,MN WELL/BORING Ej Measured Date Measured 2/2 5/25 ❑Estimated
CC tis ar XI Water-SupplyWell ❑Env.Well
Show exact location ofit5 3514 Sketch map of well or boring 7 2
in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. elow ❑above land surface
lines,roads,and buildings.N CASING TYPE(S)
L 74
at Steel ❑Plastic ❑Tile ❑Other
.________a_--_._.-___,__. _ WELLHEAD COMPLETION
W E C f`„"`
__ ____ ___t-_ T � Outside: A Pitless Adapter/Unit El At Grade Inside: ❑Basement Offset
'h Miie2 : L ❑Well Pit ElBuried ❑Well House
--- -- I .p ❑Well Pit
S 1 t ❑Other ❑Buried
1-1 Mile—I y"S'',,,,
❑Other
For temporary borings,provide additional loc ion —-r --• CASING(S)
information,a site sketch,and geology on a s parate page. Diameter t Depth f !1 A Set in oversize hole? Annular space initially grouted?
PRQp TY,pWr al fM /WMPANY NAME 4 in.from I to i( 1 9 ft. ❑Yes ❑No ❑Yes El No �j Unknown
Property owner's mailing address if different than well location address indicated above in.from ' to r) ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
/in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEN/OPEN HOLE �,b• _
WELL OWNER'S NAME/COMPANY NAME Screen from to `�f ft., Open Hole from - to
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above XI Rods/Drop Pipe ElCheck Valve(s) ❑Debris ` El Fill ❑No Obstruction "
DROP PIPE
Type of Obstructions(Describe)
Obstructions removed? f j Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO •
FORMATION ❑Not Present resent;Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. OS S
DRIFT
tt �y 127 Type ,
1 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
ANo 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 C No TN#
GROUTING MATERIAL(S) . +�7� '
Grouting Material NEAT C E N E N 1from 1 to.2 7 ft. yards la bags '
l
•
from to ft. yards bags
from to ft. yards bags
., OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? '❑Yes .c 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. . I691, .
' ;licensee Business N e - License or Registration No. , -
_.- 2I2512S
_
e Repre,entative Sigfia e" ,Certified Rep.No. Date
LOCAL COPY
" 415603 JERRY BARR
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R