Laserfiche WebLink
HE -01434-17 ID#53159 % ""y <br />MINNESOTA DEPARTMENT OF HEALTH Mi Ing to Well and Boring <br />WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />Minnesota Statutes, chapter 1031 or W�s�e„ieswNoi <br />Q <br />H 38066 <br />V <br />WELL OR BORING LOCATION <br />County Name <br />fie o <br />Township Name <br />Or <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. -II,gg.) <br />Date Sealed s <br />Date Well or Boring Constructed <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing <br />Original Depth ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />Measured Date Measured El Estimated <br />I. ❑ below ❑ above land surface <br />Numerical Street Addressor Fire Number and City of Well or Boring Location <br />Ct <br />2540 Old �ai`h Rd prono 55391 <br />WELLBORING <br />Water-Suppiywell ❑ Env. Well <br />❑ Temp. Boring ❑ Other <br />Show exact location of well or boring Sketch ap of well or boring <br />in section grid with "X." locatio r showing property <br />lines, ds, and building <br />N j �C !f 6 <br />t -X� <br />CASINGTYPE(S) <br />d--- --------- <br />i�teel ❑ Plastic ❑ Tile ❑ Other <br />WELLHEAD COMPLETION <br />W ! E <br />k Mile 1 <br />--- --- -- ---f-- I 111 <br />S L ` <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: XBasement Offset <br />El Well Pit El Buried El Well House <br />❑ Well Pit <br />El Other <br />❑Buried <br />� 1 Mile-I j'f� <br />El Other <br />For temporary borings, provide additional location <br />CASING(S) <br />Information, a site sketch, and geology on a separate page. <br />Diameter Depth) Set in oversize hole? . Annular space initially grouted? <br />1 in. from to / / ..eft. ❑ Yes ) No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAMEICOMPANY NAME <br />Vi Spbnelderj` <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />Property owner's mailing address if different than well location address indicated above <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEWOPEN HOLES <br />Screen from r/� ' to_ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS .cam! <br />Fill ',*Io Obstruction <br />❑ Rods/Drop Pipe El Check Valve(s) E] Debris E]pa <br />'` <br />Well owner's mailing address if different than property owner's address Indicated above <br />Type of Obstructions (Describe) <br />Obstructions removed? ❑ Yes ❑ No Describe <br />PUMP <br />'Not Present Present, Removed Prior to Sealing ❑ Other <br />J''U ❑ g <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HFORMATI oR <br />FORMATION <br />FROM <br />TO <br />If not IlTiown, indicate estimated formation log from nearby well or boring. <br />l A. <br />1 c <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />[XNo Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal <br />Casing Diameter t <br />in. from to ft. ❑ Perforated ❑Removed <br />in. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />Was a variance granted from the MDH for,lhis well? ❑ Yes Wo TN# <br />GROUTING MATERIAL(S) <br />{f <br />Grouting Material (�' �% . •'� fro io it. yards bags <br />f r� �L 9 <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 Xo 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 />is true to the best of my knowledge. <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Don Stodola Well Drilling Co,. Inc. 1691 <br />Licensee Business NamLicense or Registration No. <br />~e <br />01 <br />Certified Reptesenfafive Slgn ure Certified Rep. No. Date <br />{{ <br />�n <br />LOCAL COPY <br />H 8 v C 1 <br />Name of Person Sealing Well or Bodn\ <br />HE -01434-17 ID#53159 % ""y <br />