HomeMy WebLinkAboutWell Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H
WELL AND BORING SEALING RECORD Sealing No. 3 5 21. 2
County Name Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
P (Leave Wank H not known)
nennAPin
Township Narlhe Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
-nronn 11fl 73 36 p Titr. 4 : 92`7//7
GPS LOCATION- decimal degrees(to four decimal places) /
Depth at Time of Sealing / ft. Original Depth ft.
Latitude Longitude
IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location mingle Aquifer ❑Multiaquifer cn�
WELL/BORING Measured Date Measured J/")//!� J I/7/ ❑Estimated
111 Chevy Chase Dr, Orono 55391 r- XWater-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well o(bon g Q
in section grid with"X" location,showing grope ❑Env.Bore Hole ❑Other T� ft.A below ❑above land surface
lines,roads,and b din
> t c-' Steel ❑Plastic ❑Tile ❑Other
" "
-''-""' ''-''--""-- ET J 1----_ WELLHEAD COMPLETION
W Q
-'
,---•--,------r------ I
r--------'0)
'�''`�� Outside: El Pitless Adapter/Unit ❑At Grade Inside: Basement Offset
'h Mile -.- 1 ❑Well Pit ❑Buried ❑Well House
1 ' r ❑Other ❑Well Pit
s i_____
_ _ _ __ ❑Buried
I i Mile y
❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
harllc ('l r�. Diameter t Depth Set in oversize hole? Annular space initially grouted?
Property o er's ma((ng a ress if different than well location address indicated above
4..... ."+t in.from to 13'� ft. ❑Yes o ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN�H�OLLE
Well owner's mailing address if different than property owner's address indicated above Screen from��j/ to !Y3 r ft. Open Hole from to ft.
OBSTRUCTIONS
NIXT Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) � ��
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? XYes ❑No Describe RECEIVED
FORMATION
If not nown,indicate estimated formation log from nearby well or boring. PUMP
�- ❑Not Present /X Present,Removed Prior to Sealing ❑Other NOV U ? LU I,
O /7.�Type T&T Pump
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANI ANOPPrialgORONO
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
asing Diameter
in.from to ft. ❑Perforated 111 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) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
/
Grouting Material N�/97.64/ Vugfrom 4, to"b3 ft. yards bags
w'
from to ft. yards bags
from to ft. yards bags
;
OTHER WELLS AND BORINGS /
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes 1fL!�No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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 Name License or Registration No.
fiet!Re resentative a ure Certified Rep.No. Date
LOCAL COPY H 3 21 A o yrrY Y-\.
L '7 Name of Person Sealing Well or(>BoringY
HE-01434-15 ID#53159 I• 8116R