HomeMy WebLinkAbout10/05/2020 Well & Boring Sealing RecordWELL OR BORING LOCATIONMINNESOTA
DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique Well No.
or W -series No.
Minnesota Statutes, chapter 1031 kkem Wank e o, kwm)
H 380694
County Name
ile y
Township Name
Uror
Township No.
117
Range No.
23
Section No.
U4
Fraction (sm. -+ Ig.)
"L'' a �'
Date Sealed
% - - � i
Date Well or Boring Constructed
� - `� i % 3
GPS LOCATION - decimal degrees (to four decimal places)
Latitude Longitude
? .
Depth at Time of Sealing r / ft.
AQUIFER(S)
%Single Aquifer ❑ Multiaqulfer
Original Depth 131 ft.
STATIC WATER LEVEL
- _ j
Measured Date Measured /� E]Esiimated
Numerical Street Address or Fire Number and City of Well or Boring Location
WELUBORING
how exabt loco ton of wet or boring ch map of well or boring
in section grid wish "X." location, showing property
t lines, ro��ds+�nd buildings.
N =q./ n
Water -Supply Well ❑ Env., Well
❑ Temp. Boring ❑ Other �
/ I
�7 f ft. bdfow ❑ above lard surface
CASING TYPES)
- --'r-- -`-- ---`-- /
- i--- - /' • •
Steel ❑ Plastic ❑ Tile ❑ Other
WELLHEAD COMPLETION
W_ e�Outside:
❑ Pltle'ss AdapterNn(t ❑ At Grade Inside: E] Basement Offset
'h MileWell
- -T 1
s
❑ Pit Buried F1 Well House
Other El wait Pit
F-1-
❑ Burled
�1 Mlle—�
❑ Other
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.Diarrter
CASING(S)
In. from oept�r ft. El Yes oversizeoole7 ❑AY star space Nolttail ❑ Unknown
In. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Property owner's mailing address if different than well location address indicated above
939 Sad Willow Pass
in. from to ft. El Yes E] No, ❑Yes ❑ No ❑Unknown
(�
Drif LWOOd, TX 76619
SCREEWOPEN/HOLE`_
J /
Screen from / CP to 1�3 ft. Open Hole from to
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
*flods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owners address indicated above
Type of Obstructions (Describe) l k' -
Obstructions removed? es ❑ No Describe
PUMP
❑ Not Present ill Present, Removed Prior to Sealing ❑ Other
Type L%
GEOLOGICAL MATERIAL
COLOR
HARDNESS ORFORMATION
FROM
TO
If not)known, indicate estimated formation fog from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremfe Pipe ❑ Casing Perforation/Removal
�I
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 XNo TN#
GROUTING MATERIAL S)
r p�/
Grouting Material f - ' om to / � ft. yards I /� 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 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.
DUN STUDOLA WELL DRILLING C0,0 INC. 1.691
Licensee Business Name License or Registration No.
556
Certified eprese taffti Si slur ffied Rep. No. Date
LOCAL COPY
JH 380694
Name of Person Sea/Ing Well or Boring
Ht-U14J4-1 r IUB Wlbu '" 11119R
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