HomeMy WebLinkAboutre: well record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 355460
Sealing
County Name WELL AND BORING SEALING RECORD Minneso aOUnique Well No.
No.
Hennepin Minnesota Statutes,Chapter 1031 or W-series N
(Craw blank M not No.
Township Name Township No. Range No. Section No. Fraction(sm.-,Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23_ 20 _ 1:11 ttE 141.4 2./ ie
GPS LOCATION-decimal degrees(to four decimal places) 00. /
Latitude Longitude Depth at Time of Sealing /V/ ft. Original Depth ft.
IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �f R
25'>R 7 � Y ��' OronofW LL/BORING y�Measured Date Measured' /}� II]Estimated
W �d((Water-Supply Well ❑Monit.Well 7a r
Show exact location of well or boringEnv.Bore Hole Sketch map of well or boring
in section grid with"X" location,showing property ❑ ❑Other 6! ft.*below ❑above land surface
N I+, lines,roads,and buildings CASING TYPE(S)
Ql, NA Steel ❑Plastic ❑Tile ❑Other
.. ----''---- ----_f--" WELLHEAD COMPLETION
;___ I Outside: ❑Pitless Adapter/Unit ❑At Grade Inside)(on
Basemen
'h Mile .E:. R 0 Z 2418
❑Well Pit ❑Buried ❑Well House
1 '� ID Other ❑Well Pit
1 1 Mile —1 �`ror/ ❑B�,;edCllY OF ORONO
_, J ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Tim »t" Diameter Depth I Set in oversize�/// hole? Annular space initially grouted?
Property� owner
'mailing,address ft different than well
lllocation address indicated above g/f in.from to/5 ft. ❑Yes XNo ❑Yes ❑No ❑Unknown
4931 Vincennes Ci; ftp in.from to - ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Cape Coral, FL 33904
in.from to ft. Li Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
r
Well owner's mailing address if different than property owners address indicated above Screen from /53to./51 ft. Open Hole from to ft.
OBSTRUCTIONS
yRods/Drop Pipe ❑Check Valve(s) ❑Debris Li Fill ❑No Obstruction
- Type of Obstructions(Describe)aots4 024145 } e:,
,72,14,45
HARDNESS OR Obstructions removed?
GEOLOGICAL MATERIAL COLOR FORMATION FROM TO XYes ❑No Describe-
If no known,indicate estimated formation log from nearby well or boring.
PUMP
,r� 'Il�Not Present ❑Present,Removed Prior to Sealing ❑Other
5 6 451 fTy*pe
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
sing 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 No TN#
GROUTING MATERIAL(S) (One bag of cement= lbs.,one bag of bentonite=50 lbs.)
•
Grouting Materi0W47—C646177
r� from _to/ ,ft: yards 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? ❑YesVI o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f
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.
.. 2 - I - !a
C eserftative S' ature Certified Rep.No. Date
LOCAL COPY " 355460 r ' " ``~'" '''
yytt
Name of Person Sealing Well or Bo tng
HE-01434-15 ID#53159 ' ensA