HomeMy WebLinkAboutwell/borning seal record Q
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 1 8 6 4 0
Sealin
County Name WELL AND BORING SEALING RECORD MinnesotaoUnique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin yea edkAnotkn
anmxn)
Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed
Orono 117 23 04 S St IN 11 -17- 1 y
GPS LOCATION—decimal degrees(to four decimal places) ;/
Depth Before Sealing I ) ! _ft. Original Depth ft.
Latitude Longitude
A UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring/� Location Lingle Aquifer LIMultiaquifer ,„,i-I r�
225 Old Crystal Bay Rd S. Orono ELL/BORING Measured 111 Estimated Date Measured
Water-Supply Well 10 Monit.Well
Show exact location of well or boring Sketch map of well or bori
in section grid with"X." location,showing propel ❑Env.Bore Hole ❑Other 7P ft. 1 below ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
3Steel ❑Plastic ❑Tile ❑Other
'--'---'--'------`--'-----' //��•^'--R /\ ELLHEADSteelCOMPLETION
w : E
T l� -'/ Outside: ❑Well House ❑At Grade Inside: [Basement Offset
ifyMile
HI ❑Pitless Adapter/Unit ❑Buried 111 Well Pit
r R
II]Buried
S ❑Well Pit
['Other
I I Mile----I --' ❑Other
PROPERTY OWNER'S NAME/COMPANY NAMI° CASING(S)
Norman/Angela Hay Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above -3 ii I 0 El Yes [ No ❑Yes El No ❑Unknown
Sionnet from to ft.
44 Chemin de Sionnet in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1254 Jussy
Switzerland 1254 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE�I
Well owner's mailing address if different than property owner's address indicated above Screen from ' V to r2ft. Open Hole from to ft.
OBSTRUCTIONS
(ji Rods/Drop Pipe ❑Check Valve(s) ❑Debris` El Fill ❑No Obstruction
Type of Obstructions(Describe) �rO /•!"f VW y43
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 1 Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. r�! v.-, r {
Type J
a f,
NRemoved ❑Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
j No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
I
Type of Perforator
VARIANCE
RECEIVEDWas a variance granted from the MDH for this well? ❑Yes If No TN#
GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.)
MAY 2 3 20141 1
Grouting Material 4t ( <<^k -v+- from C to 17 7 ft. yards 6 bags
Ci„ OF ORONO 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 II o 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 f , TNC. 1691
Licensee Business Nam License or Registration No.
..
�
-6-6.
,;: �►'� . 558 /--,:?/-/y
Ce .e pr entative Signature • Certified Rep.No. Date
LOCAL COPY H 31$640 " ` '
Name of Person Sealing Well or Boring
HE-01434-14 IC#140-0423 5/13R