HomeMy WebLinkAbout08-03-2020 Well and Boring Sealing RecordHE -01434-16 ID# 63159 % 9117R
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No.
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 Or W -series No.
" J 3 7 5 5 9 a
WELL OR BORING LOCATION
County Name
TT
Township Nam
01
Township No.
117
Range No.
23 1
Section No.
17
Fraction (sm. –� Ig.)
Date Sealed
yr ✓.L
Date Well or Boring Constructed
GPS LOCATION – decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing /q�ft.
Original Depth h.
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
✓
Measured Date Measured ) ) El Estimated
ft. g below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
1P75n o 1, )" h.
WELLBORING
} Water -Supply Well ❑ Env. Well
❑ Temp. Env. Well ❑ Other
Show exact location of well or boring r r e ch map Qf well or boring
in section grid with "X" 5 5 - adcation, showing property
N lines, roads, art b dlhgs.
CASINGTYPE(S)
steel ❑ Plastic ❑ Tile ❑ Other
--'--- --'r-- ----------
'-- -
W i I l ET
__Y-_ ___�------ r
tk Mile
--4--- -------------------- I
s l1
�1 Mile—� 0 Y l''
For multiple temporary environmental wel(s!�vfde additional loc VU
WELLHEAD COMPLETION
Outside:�Piiless Adapter/Unit ❑ At Grade Inside: El Basement Offset
❑ Well Pit ❑ Burled Well House
❑ Well Pit
❑ Other
❑ Buried
❑ Other
CASING(S)
information, a site sketch, and geology on a separate page. `
Diameter Depth Set in oversize hole? Annular space initially grouted?
l in. from to-"- 7 ft. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Q
Property owner's mailing a ress d ifferen t an wel oration address indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
In. from tc ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
toit. Open Hole from to ft.
Screen from�
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
YRods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owner's address Indicated above
Type of Obstructions (Describe) A–
Obstructions removed? Yes ❑ No Describe
PUMP
Present resent, Removed Prior to Sealing
❑ Pg ❑ Other
Type – -
GEOLOGICAL_ MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TONot
If not known, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe E] Casing Perforation/Removal
_
asing 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 wail? ❑ Yes XNo TN#
GROUTING MATERIAL(S) (One bag of cement = g4 lbs., one bag of bentonite = 50 lbs.)
Grouting Material frpmr to�� % ft. yards bags
from to ft. yards bags
from to It. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes 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
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
is true to the best of my knowledge.
Dan Stodola Well Drilling Co., Inc. 1691
Licensee Business Name License or Registration No.
gAi �i; resen ague"Sig ure Certified Rep. No. Date
LOCAL COPY
JH 3 7 5 5 9 9
Name of Person Sealing Well or Bor!
HE -01434-16 ID# 63159 % 9117R