HomeMy WebLinkAbout2018 Well & Boring sealing RecordHE -01434-15 ID# 53159 8r16R
MINNESOTA DEPARTMENT OF HEALTH MinnesotaWell and Boring
H `,� 5 15 5 6 6
WELL OR BORING LOCATION
Sealing
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
• 1 �J
County Name
Minnesota Statutes, Chapter 1031 or W -series No.
P (kea- dank It not kn—)
';1�'Ii11'L 11'i
Township Name
Township No.
Range No.
Section No.
Fraction (sm. -. Ig.)
Date Sealed
Date Well or Boring Constructed
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117
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I
GPS LOCATION - decimal degrees (to four decimal places)
Depth at Time of Sealinft.
Original Depth ft.
Latitude Longitude
IFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
L] Estimated
Measured Date Measured
Numerical Street Address or Fire Number and City of Well or Boring Location
WE
-S/C.-Y;-
.3.449 Casco ClrC1: 0rO11J e1•' L'a
[Water -Supply Well ❑ Monit. Well
Show exact location of well or boring Sketch map of well or b ing
in section with "Xti location, showing
Env. Bore Hole Other
❑ ❑
ft.f below above land surface
❑
grid prix y
N lines, roads, and buildin s.
CASINGTYPE(S)
Steel E] Plastic ❑ Tile E] Other
WELLHEAD COMPLETION
w E T !�
--I j
;--- --;--- ------------
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: El Basement Offset
'h Milen
Well Pit ❑ Buried ❑ Well House
--- -------------- _
❑ Well Pit
❑ Other
S
❑ Buried
1 Mile
❑ Other
PROPERTY OWNER'S NAME/COMPANY NAME
CASING(S)
Diameter 'I Depth Set in oversize hole? Annular space initially grouted?
Property owners mai ing a dress if itfere t an we I lo'c*AiA AA#igicated above
��
^� in. from E to12sp—, ft. El Yes X No El Yes ❑ No ❑Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
WELL OWNER'S NAME/COMPANY NAME
SCREEN/OPEN HOLE
Screen from _/ 9Q to/JeZ ft. Open Hole from to ft.
Well owner's mailing address if different than property owner's address indicated above
OBSTRUCTIONS
Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions (Describe)x ✓L -
Obstructions removed? X Yes ❑ No Describe
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FROM
TO
FORMATION
PUMP
❑ Not Present Present, Removed Prior to Sealing ❑ Other
If not known, indicate estimated formation log from nearby well or boring.
Type 3Ar
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
o Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
Casing 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 = 94 lbs., one bag of bentonite = 50 Ibs.)
Grouting Material f�T�Liromto-1�� ft. yards bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes No How many?
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
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.
Dj.' OdODULA WEILL DRILLING CO., 1AC. 1691
Licensee Business Name License or Registration No.
558
ewr6 ,;,Representative Sig tore Certified Rep. No. Date
[F
LOCAL COPY
JH 355566
Name of Person Sealing Well or Boring
HE -01434-15 ID# 53159 8r16R