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HomeMy WebLinkAboutWell Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well d BoringH WELL OR tiORING LOCATION Sealing No. 3521_76 Coun Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. 1 (Leave blank H rqt knovm) Township Name 1 Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed Orman It7 23 21 .Nti N1 N*i / /to /1 GPS LOCATION–decimal degrees(to four decimal places) / i Depth at Time of Sealing at- ft. Original Depth ft. Latitude Longitude IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑.Muitaquifer ,MM 2570 Lydiard Ave, Orono WELL/BORING Measured Date Measured AMC )5,0 klij Estimated �N/nv.Bore Hole ater-Supply Well ❑Montt.Well Show exact location of well or boring Sketch map of wet or boring ALS.E in section grid with"X" location,showing property ❑Other _ _ft.%below ❑above land surface N • lines,roads,ab du it CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other WELLHEAD COMPLETION — W ET --- RECEIVED Outside:gPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset 7 'k Mile ['Well Pit ❑Bried a Well House ❑Other Well Pit JAN 7 6 2018 S , �1 Mile ( ❑Buried ❑Other CITY OF ORONO PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) nr0g (11411rk Diame es) r Depth Set in oversize hole? Annular space initially grouted? Property otbfter's Mailing address if different than well location address indicated above // in.from © to 3 r i ft. Ill Yes X.No ❑Yes ❑No ❑Unknown 5585Harding Lanein.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Sharevood, >I 55331 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE + f 1 Well owner's mailing address if different than property owner's address indicated above Screen from 3# toi.. ft. Open Hole from to ft. OBSTRUCTIONS , f pQ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill j� ❑No Obstruction Type of Obstructions(Describe)j4$J ,R (- . An9/0 GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes FORMATION No Describe If not known,indicate estimated formation log from nearby well or boring. PUMP Not Present ❑Present,Removed Prior to Sealing ❑Other u Type_ METHOD USED TO SEAL ANNU AR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE Xaso Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal mg 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 X No TN# GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Material A1fgreeinfildrom 0 to 3s ft. yards25- bags 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 XNo 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. Doti Stodola Well i, Tim; Co,. Inc. 1691 • Licensee Busine s me License or Registration No. ` .f 1. -,//' / Ce ifi a esentative Signature Certified Rep.No. Date LOCAL COPY H 352176 ,�-I , �. F. . .. Name of Person Sealing Well or Borng' HE-01434-15 ID#53159 8/16R