HomeMy WebLinkAbout07-27-2021 Well and Boring Sealing RecordWELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
County Name WELL AND BORING SEALING RECORD Minnla
eso oUnique Well No,
Minnesota Statutes, chapter 1031 or W -series No.
7Yonna;'r�n (Lasea�n"aww )
H 388434
Township Name Township No. Range No. Section No. Fraction (sm. Ig.)
rano W SW
Date Sealed
1121
Date Well or Boring Constructed
Depth at Time of Sealing ft.
AQUIFER(S)
Single Aquifer ❑ Multiaquifer
Original Depth ft.
STATIC WATER LEVEL
❑ Measured Date Measured 07/27/2021 ❑ Estimated'
ft. ❑ below ❑ above land surface
GPS LOCATION — decimaidegrees (to four decimal places)
Latitude Longitude
Numerical Street Address or Fire Number and City of Well or Boring Location
e�+ 1 �nrwv /�
_ IL.�r+Slflp� ViKid
WELUBORING
�vl Water -Supply Well ❑ Env. Well
1�
❑ Temp. Boring ❑ Other
S ow exact location of we( b g Sketch map of well or boring
in section grid with °X." location, showing property
N lines, roads, and buil ings.
I I I I
CASING TYPES)
Steel ❑ Plastic, ❑ Tile ❑ Other
--i--- --f-- ---- ---t-- d `��•�
W E
'h Mile ` �! J�
--- --- -- --- - 1
S �
{1 Mile i
.
WELLHEAD COMPLETION
Outside: Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset
❑ Well Pit ❑ Buried ❑ Well House
❑Other E) Well Pit
E) Buried '
El Other
For temporary borings, provide additional location ti�S
information, a site sketch, and geology on a separate page.I
CASING(S)
Diameter Depth Set in oversize hole? Annular space initially grouted?
tt in. from_= to 75 El ft. Yes No Yes No X Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWN'NAME/COMPANY NAME
L. ► y�
Pirdpppbrty owner's mairing aoare� �f 8 L......_. well iocation address indicated above
Udh W xhR
tfxzpisior, W. 55331
SCREEWOPEN HOLE
Screen from 75'__ to 79' ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
Rod P
Drop ❑ 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? XYIas ❑ No Describe
PUMP
❑ Not Present X Present, Removed Prior to Sealing ❑ Other
Type -;11 n :i" P_ Y• 9 i D l e
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
IMETHOD 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
-1ri f t
1
79
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 ANo TN#
GROUTING MATERIAL(S)
n
Grouting Material N e a t . 1 a 1Z from_ to�9ft. yards v bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Ocher unsealed and unused well or boring on property? ❑ Yes+'] No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or baring 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.
non Stodola Uell Drillim So Inc 1691
Licensee Business Name License or Registration No.
558
Certified Representative Signature " Certified Rep. No. Date
I f
LOCAL COPY
H}` 8 4 3 4
Name of Person Sealing Well or Boring
HE -01434-17 ID# 53159 11/19R