Laserfiche WebLink
HE -01434-16..- ' ID#53159 [ 9117R <br /># MINNESOTA EPARTMENT OF HEALTH Minnesota Well and Boring.. - <br />H 365 3 0 <br />LOCATION <br />WELL OR BORING <br />�IVELL AND B ING SEALING RECORD MinnSealleso aoUnique Well No. <br />County Name <br />tis <br />Minnesota Statutes, Chapter 1031 or-sere <br />i <br />Towns ip a Township No. Range No. Section No. Fraction (sm. - Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />Orem 1 <br />GPS LOCATION - decimal degrees (to four decimal places) <br />/ <br />Depth at Time of Sealingft. <br />Original Depth R. <br />Latitude Longitude <br />OUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />C M n , / <br />Measured Date Measured �('�" Estimated <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />WELL/BORING <br />4710 Augusta St, Orono <br />ater-Supply Well ❑ Env. Well <br />❑Temp. Env. Well ❑Other <br />- _�__ft. below ❑above iandisuriace <br />Show exact location of well or boring Sketch ap of well or boring <br />in section grid with location, showing property <br />N lines, ro ds, and buildings. <br />CASING TYPES) <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />i ------ <br />WELLHEAD COMPLETION <br />W E J <br />-4---- <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset <br />i <br />Is <br />El Well Pit Buried Well House <br />_ <br />❑ Wel it <br />S 4 <br />❑ Other <br />S > <br />❑ Buried ; <br />�i Mile ❑ <br />❑ Other <br />For multiple temporary environmental �ells, ovide additional location <br />CASING(S) <br />information, a site sketch, and geology on a se arate page. <br />Diameter/` / Depth / Set in oversize hole? Annular space initially grouted? <br />_&Lin. from t/Vto ft. ❑Yes j�No -1Yes ❑ No ElUnknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Properly owners mailing a ress if different than well location address indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />18215 45thAveN, Ste D <br />in. from to ft. E] Yes ❑ No ❑ Yes E1 No El Unknown <br />='!ty <br />Plymouth, 55446 <br />SCREEN/OPEN HOLE <br />t , <br />2 <br />from 1G to It. Open Hole from to ft. <br />WELL OWNER'S NAMEICOMPANY NAMEof <br />WELL <br />OBSTRUCTIONS <br />Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owners mailing address if different than property owners address indicated above <br />Type of Obstructions (Describe)..L/�%!fi!J� !^' � /" �%-0,0 <br />ir <br />Obstructions removed? Xes ❑ No Describe <br />PUMP <br />Not Present Present, Removed Prior to Sealing El Other <br />❑ 9 <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not limown, indicate estimated formation log from nearby well or boring. <br />METHOD USED TO SEAL ANNUL R SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal <br />sing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />in. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes No TN# <br />GROUTING MATERIAL(S) (One bag of cement = b4 lbs., one bag of bentonite = 50 lbs.) <br />/ <br />Grouting Materlayw'gr4o�&I&Xorn I/ —, to11-ft. yardbags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes XNo How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />is true to the best of my knowledge. <br />Don Stodola Well Drilling Co. .Inc. 1591 <br />Licensee Business Pame License or Registration No. <br />r� <br />i e resen 8iiv Signature Certified Rep. No. Date <br />�_ _ (/t` <br />LOCAL COPY <br />Q <br />JH 3 6 5 3 0 <br />Name of Person Sealing Well or Bonn <br />V <br />HE -01434-16..- ' ID#53159 [ 9117R <br />