HomeMy WebLinkAboutWell Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 352211
WELL AND BORING SEALING RECORD Sealing No.
County Name Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin
(Leave nark n m known)
Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 -07 Sr' SE SS /2/y/!l?
GPS LOCATION-decimal degrees(to four decimal places)
Depth at Time of Sealing 92 Latitude Longitude
ft. Original Depth ft.
AQUIFERS) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Mukiaquifer �rv►�A,��/
't(77J,�,3'!ghwood ' C�+sl1. WELL/BORING xMeasured Date Measured S.n r f��/7 T ❑Estimated
J ��4 Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or boring
in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other f(/l",i4.Ja ft. gbelow ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
A, •
J� y
t�Steel ❑Plastic ❑Tile ❑Other
WELLHEAD COMPLETION
w , : ; , ET �
__;__ _r_
_ l i. .f___ ! Outside: ❑Pities Adapter/Unit ❑At Grade Inside: XBasement Offset
; Mile Well Pit ❑Buried ❑Well House
--;-- i T RECEIVED
EIVED
s .1 ❑Other ❑Well Pit G
) 1 Mlle--1 9 ❑Buried
Il ❑Other JAN 1 02018
PROPERTY OWNER'S NAME/COMPANYCONAME - CASING(S)
Scott �.now Diameter Depth , Set in oversize hole? Annular yyy���aaa C'7W t' r
Property owner's mailing address f different than well location address indicated above NO
Z r�in.from 6 to38 ft. ❑Yes KNo ❑Yes IC 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 HOLE
3Well owner's mailing address if different than property owner's address indicated above Screen from ,V1140 to L ft. Open Hole from to ft.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill [ to Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO Obstructions removed? ❑Yes ❑No Describe
If not nown,indicate estimated formation log from nearby well or boring. PUMP
L/ 2 XNot Present ❑Present,Removed Prior to Sealing ❑Other
Type
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 TN#
GROUTING MATERIAL(S) (One bag of cement= lbs.,one bag of bentonite=50 lbs.)
'
Grouting Material 6l/4Q S tJ7 �from,_t,gr___ to 44/2ft. yards I bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS e
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I�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.
: ✓ / 7
nese alive ature Certified Rep.No. Date
E
LOCAL COPY H 352211
Name of Person Sealing Well or Boring,
HE-01434-15 ID#53159
6/i6R