HomeMy WebLinkAbout06-10-2021 Well & Boring Sealing RecordWELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 385563
County Name WELL AND BORING SEALING RECORD MinnesoSealing ta Unique Well No.
Minnesota Statutes, chapter 1031 No
or Wus erie kr—)
Township Name Township No.flange No. Section No. Fraction (sm. -+ Ig.) Date Sealed ) Dale Well or Boring Constructed
S
GPS LOCATION -decimal degrees (to tour decimal places) +y
Depth at Time of Sealing ! l ft. Original Depth—ft.
Latitude Longitude
NUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer
32.47 G a 5 c o Uri, U r o o o J�) 3 6 4 WELL/BORING Measured Date Measured ❑ Estimated
X Water -Supply Well E) Env. Well
Show exact location of well or boring Sketch map of well or boring
r.
in section grid with "X" location, showing property / ❑ Temp. Boring ❑ Other ft. ['below ❑ above land surface
lines, roads, and buildings:°
N f CASINGTYPE(S)
'[Steel ❑ Plastic ❑ Tile ❑ Other'
i h f r ' WELLHEAD COMPLETION
W t E T Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: -r Basement Offset
f
'b Mile Well Pit El Buried Ll
[:)'Well
yWell House
'
„
1 ❑
' -1-711 s I Other ,_I -
—1 Mile - ❑ Buried
❑ Other
For temporary borings, provide additional locati n CASING(S)
information, a site sketch, and geology on a se rate page. Dia ter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME in. from to IWft. ❑ Yes ❑ No ❑ Yes ❑ No Yunknown
d LLC
Property owner's mailing address If different than well location address Indicated above in. from to ft. ❑ Yes ❑ No Yes ❑ No ❑ Unknown
153 1� Lake St in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Wayzata, k1h 55304 SCREEWOPEN HOLE
fj �J
WELL OWNER'S NAME/COMPANY NAME Screen from i« / t. -L7 -/-ft. Open Hole from to
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions (Describe)
Obstructions removed? YYes ❑ No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESSORFROM TO Not Present Present, Removed Prior to Sealing ❑ Other
FORMATION ❑
If not nown, indicate estimated formation log from nearby well or boring. Type A f
4 I METHOD USED T DEAL ANNULAR SPACE BE EEN 2 CASINGS, OR CASING AND BORE HOLE
5(No Annular Space Exists ❑ Annular Space Grouted with Tremle 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 WNo TN#
GROUTING MATERIAL S) --��-- s
Grouting Material I/�° f frt3m to ft. yards w 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 XNo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING 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.
von Stodola well Drilling Co., Inc. lbyl
Licensee Business Name License or Registration No.
°
todriM frep e entatrbe Signature —� Certified Rep. No. Date
LOCAL COPY H J 8 5 5 63
Name of Person Sealing Well or Bq rag
HE -01434-17 ID# 53159 '�, 11/19R