HomeMy WebLinkAbout06/30/2021 Well and Boring Sealing RecordWELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH SMinnesota ealing Nowell and Boring
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
H C 73 4
County Name
Ae1111l?' 111
Minnesota Statutes, chapter 1031 or W -series No.
(Less blankNnal k—)
Township Name7
Township No.
Range No.
Section No.
Fraction (sm. - Ig.)
Date Sealed
Date Well or Boring Constructed
Jrono
117
23
1 1U
N ' LIE
- -
GPS LOCATION - decimal degrees (to four decimal places)
Latitude Longitude
Depth at Time of Sealing ft.
AO IFER(S)
Single Aquifer ❑ Multiaquiler
Original Depth ft.
STATIC WATER LEVEL
Measured Date Measured /0 - �� � � t] Estimated
b .2
✓ ft. 19below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
1201 t3 r i ce r .� t �% r O it
WELL/BORING
,,,
Water -Supply Well ❑ Env. Well
El Temp. Boring El Other
Show exact location of well or boring Sketch map of well or
in section grid with "X° location, showing prop
N lines, roads, and build
oring
rty
f gs.
CASING TYPE(S)
t
`-----`-- JL! '
Steel El Plastic ❑ Til e ❑ Other
WELLHEAD COMPLETION
IN
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: Basement Offset
t I i
I t I 'h Mile
'
S
�
F-1 well Pit El Buried Well House
❑ Other El wait Pit
Buried
I Miley
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.
i
❑ Other
CASING(S)
Diaptgter Depth Set in oversize hole? Annular space Initially grouted?
d in. from to;Q3 ft. ❑ Yes ❑ No ❑ Yes ❑ No `Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAMEICOMPANY NAME
Property owner's m]aili�ngaddress If dirent than well location address Indicated above
104 Gy
in. from to ft. ❑ Yes ❑ No El Yes ❑ No ❑Unknown
SCJ
SCREEWOPEN HOLE
.3a
WELL OWN R'S NAME/COMPANY NAME
Screen from to C� ft. Open Hole from to ft.
,O�-BBSTRUCTIONS
r'dlods/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)i►-
Obstructions removed? Wes ❑ No Describe
PUMP
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
❑ Not Present Present, Removed Prior to Sealing ❑ Other
Type
If not known, indicate estimated formation log from nearby well or boring.
%)
METHOD USI�O SEAL ANN LAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annuiart lace Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal
l
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 Ko TN#
GROUTING MATERIAL )
Grouting Material 1^ ^- •fm ! to ft. yards 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 No 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 Stodole Well Drilling Co#. Inc. 1091
Licensee Business Name License orrr Registration No.
Ctfir ke reseritat e Sigel e` Certified Rep. No. Date
,
�, ' O`'�"'
LOCAL COPY
H ? ( 7 4
Name o/ Person Sealing Well or Borlpg
HE -01434-17 ID# 53159