HomeMy WebLinkAbout12/23/2020 Well & boring Sealing RecordHE -01434-17 ID#53159 N- '— 11f19R
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
H 38148
OR BORING LOCATION
WELL
Sealing No.
WELL AND BORING SEALING RECORD Minnesota or W -series UniquNo. e Well No.
Minnesota Statutes, 1031
Q
County Name
L/ r
�
chapter (Lem blank Bnor k,wm)
7 � •�
Township Na a
Township No.
Range No.
Section No.
Fraction (sm. -� Ig.)
Date Sealed
Date Well or Boring Constructed
21
GPS LOCATION - decimal degrees (to four decimal places)
t r
l
�r�
Depth at Time of Sealing ft.
Original Depth I ft.
Latitude Longitude
AQUIFER(S)
Single Aquifer ❑ Mulliaquifer
STATIC WATER LEVEL
j '7
Measured Date Measured ! _:4 ` _%� ..� `�❑ Estimated
Numerical Street Address or Fire Number and City of Well or Boring Location
ELUBORING
IM L<)mR Linda. Oril 1
['Water -Supply Well ❑ Env. Well
Show exact location of well or boring Sketch ma of well or boring
in section grid with "X:" locat�o , of,
property
❑ Temp. Boring ❑ Other
j m i
f ft. [below El above land surface
N li 11 adts buildings.
111
CASING TYPE(S)
3y
Steel ❑ Plastic ❑ Tile ❑ Other
------ ------ ---F-- ---t--
W E�--i__• -_r-_ __ �__ ___�__ �-A '� ' �- . �
WELLHEAD COMPLETION -
Outside: RdPitless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset
,� �h
Mile .
E] Well
❑ Well Pit ❑ Burred House
r= 1
❑Well Pit
S
❑ Other
❑ Buried
I Mile
- ❑ Other
For temporary borings, provide additional location
CASING(S)
information, a site sketch, and geology on a separate page.
Diameter Depth T] Set in oversize hole? Annular space initially grouted?
in. from to / / c1 ft. F1 Yes 'VNO ElYes ElNo ElUnknown
PROPERTY OWNER'S NAME/COMPANY NAME
Pei StD
in. from to ft. El E]No ❑Yes ❑ No ' ❑ Unknown
Property r'sr y ownemailing address if differen t an well location address Indicated above -
t7ier
4.2 Lily Lane
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Minnetrista, NN 55331
SCREENIOPEN HOLE
Screen from { 7 0 to f L? jt. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
Rods/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) �) -
Obstructions removed? VYes ❑ No Describe
PUMP
Present [Present, Removed Prior to Sealing El Other
❑ g
Type�4t-
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TONot
If not known, indicate estimated formation log from nearby well or boring.
METHOD U§ED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ 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 well? ❑ Yes XNo TN#
GROUTING MATERIAL S)
13 ,,�
Grouting Material _ rY� ( 0 from- 6 to / Vi ft. yards 1 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 yNo 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.
Don Stodola Moll Drillimco., Tne. Z6C)l
Licensee Business Name License or Registration No.
f
Certil%ed Pepresenfative Signaft(ey R -- Certified Rep. No. Date
LOCAL COPY
H 8 Li. 3
Name of Person Sealing Well or Boring
HE -01434-17 ID#53159 N- '— 11f19R