HomeMy WebLinkAbout09-13-2020 WELL AND BORING SEALING RECORDHE -01434-17 ID#53159 % ""y
MINNESOTA DEPARTMENT OF HEALTH Mi Ing to Well and Boring
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, chapter 1031 or W�s�e„ieswNoi
Q
H 38066
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WELL OR BORING LOCATION
County Name
fie o
Township Name
Or
Township No.
Range No.
Section No.
Fraction (sm. -II,gg.)
Date Sealed s
Date Well or Boring Constructed
GPS LOCATION — decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing
Original Depth ft.
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
Measured Date Measured El Estimated
I. ❑ below ❑ above land surface
Numerical Street Addressor Fire Number and City of Well or Boring Location
Ct
2540 Old �ai`h Rd prono 55391
WELLBORING
Water-Suppiywell ❑ Env. Well
❑ Temp. Boring ❑ Other
Show exact location of well or boring Sketch ap of well or boring
in section grid with "X." locatio r showing property
lines, ds, and building
N j �C !f 6
t -X�
CASINGTYPE(S)
d--- ---------
i�teel ❑ Plastic ❑ Tile ❑ Other
WELLHEAD COMPLETION
W ! E
k Mile 1
--- --- -- ---f-- I 111
S L `
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: XBasement Offset
El Well Pit El Buried El Well House
❑ Well Pit
El Other
❑Buried
� 1 Mile-I j'f�
El Other
For temporary borings, provide additional location
CASING(S)
Information, a site sketch, and geology on a separate page.
Diameter Depth) Set in oversize hole? . Annular space initially grouted?
1 in. from to / / ..eft. ❑ Yes ) No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAMEICOMPANY NAME
Vi Spbnelderj`
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Property owner's mailing address if different than well location address indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLES
Screen from r/� ' to_ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS .cam!
Fill ',*Io Obstruction
❑ Rods/Drop Pipe El Check Valve(s) E] Debris E]pa
'`
Well owner's mailing address if different than property owner's address Indicated above
Type of Obstructions (Describe)
Obstructions removed? ❑ Yes ❑ No Describe
PUMP
'Not Present Present, Removed Prior to Sealing ❑ Other
J''U ❑ g
Type
GEOLOGICAL MATERIAL
COLOR
HFORMATI oR
FORMATION
FROM
TO
If not IlTiown, indicate estimated formation log from nearby well or boring.
l A.
1 c
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
[XNo Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal
Casing Diameter t
in. from to ft. ❑ Perforated ❑Removed
in. from to ft. ❑ Perforated ❑ Removed
Type of Perforator
Was a variance granted from the MDH for,lhis well? ❑ Yes Wo TN#
GROUTING MATERIAL(S)
{f
Grouting Material (�' �% . •'� fro io it. yards bags
f r� �L 9
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes Xo 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.
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
Don Stodola Well Drilling Co,. Inc. 1691
Licensee Business NamLicense or Registration No.
~e
01
Certified Reptesenfafive Slgn ure Certified Rep. No. Date
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LOCAL COPY
H 8 v C 1
Name of Person Sealing Well or Bodn\
HE -01434-17 ID#53159 % ""y