HomeMy WebLinkAbout03/02/2021 Well & Boring Sealing RecordIDN 53159 11/19R
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique Well No.
Minnesota Statutes, chapter 1031 or W Sen es�No.
H `� 8 1552 J—
J 5 5 2
WELL BORING LOCATION
Na
County Name
Tenn@ itT
Township Name
row
Township No.
117
Range No.
23 1
Section No.
17
Fraction (sm. - Ig.)
1WTA S7
Date Sealed
1
Date Well or Boring Constructed
GPS LOCATION — decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing1 i�ft.
Original Depth ft.
• -
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
t
Date Measured `� • ❑ Estimated
I
ff
lr ft. Ixtielow ❑ above land surface
NumericalStreet
i7Address or Fire Number and City of Well or Boring Location
. 3
2205 ,,� M{Measured
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WELL/BORING
Water -Supply Well ❑ Env. Well
❑ Temp. Boring ❑ Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X:' location, showing property
N lines, roads, and buildings.
1�
I t I �y
--i--- --A-- ---F-- ---l-- ! SFX,
777777
W ET
f _ I I- I
'h Mile
S
1 Mlles
For tempolary borings, provide additional location
information, a site sketch, and geology on a separate page.
CASING TYPE(S) -
(�-Steel ❑ Plastic ❑ Tile ❑ Other
WELLHEAD COMPLETION -
Outside: ❑ Pitless Adapter/Unit [I At Grade Inside: Basement Offset
❑ Well Pit ElBuried -1 Well House
El Other El Well Pit
❑ Buried
❑ Other
CASING(S)
Diarrteler Depth Set in oversize hole? Annular space initially grouted?
� in. from ' to '- J, ft. ❑ Yes ❑ No ❑ Yes ❑ No jXunknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Boli Ness
Property owner's mailing address if different than well location address Indicated above
SCREEWOPEN HOLE
+ LT
Screen from ` =�1,--)3 to 5: ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
M Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions (Describe) f `r
Obstructions removed? es ❑ No Describe
Well owner's mailing address it different than property owners address indicated above
PUMP
❑ Not Present aPresent, Removed Prior to Sealing ❑ Other
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
t
{
a
METHOD USED 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
'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 KNo TNN
GROUTING MATE IAL(S)
(� f
Grouting Material from to V / ft. yards •-It 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 P"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
is true to the best of my knowledge.
Don Stodols I -Tell Drilling Co 1691
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
Licensee Business Name License or Registration No.
3j L 1
'Certified hepresentafive Signature Certified Rep. No. Date
Ae
LOCAL COPY
H 3 5 5 2
ng
Name of Person Sealing ell or boring
IDN 53159 11/19R