HomeMy WebLinkAbout02-15-2022 Well & Boring Sealing RecordHE -01434-17 ID# 53159 1 N 11/198
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD MinnSealleso aoUnique Well No.
Minnesota Statutes, chapter 1037 or W-series No.
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OR 80RING LOCATION
County
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To nship Name
D No
Township No.
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Range No.
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Section No. I
33
Fraction (sm. — Ig.)
04
Date Sealed
— 5 20zz
Date Well or Boring Constructed
GPS LOCATION — decimal degrees (to four decimal places)
Latitude L C Longitude C C I T
Depth at Time of Sealing-1-5--ft.
Original Depth % ` C ft.
AQUIFER(S)
Single Aquifer ❑ Mulliaquifer
STATIC WATER LEVE , r,T
IU V ` L
� Measured Date Mea , L ❑ Estimated
ft. ❑ below ❑ above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
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pt
WELL/BORING
❑ Waler-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.
CASINGTYPE(S)
S
❑ Steel ❑ Plastic ❑Tile Other -,ZS �uLu,w (EM
------ -- j--- --- `----------
WELLHEAD COMPLETION
W E
II I I
___ __ _____T
'h Mile
r 1��
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s "�+ 1 �lo�
Outside: PI1ess Adapter/Unit ❑ At Inside: B nt set
❑ Well Pit L1Buried Well House
❑wall Pit
ther
❑ Buried
�1 Mile
❑ Other
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.
CASINGS)
Diame er Dept Set in oversize hole? Annular space initially grouted?
in. from Io L ft. L] Yes N'No ❑ Yes �No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
Prroop�perty owner's mailing address if different than well location address indicated above
275a �G Ej,yEy PW�/�q
SCREEWOPEN HOLE
Scr rom ft. le.�to ft.
A
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AM
WELL OWNER'S NCOMPANY NA E
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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
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Type of Obstructions (Describe)
Obstructions removed? ❑ Yes ❑ No Describe
PUMP
of Present Present, Removed Prior to Sealing Other
❑ g ❑
Type
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
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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
sing Diameter
n. from ft. Pe d ❑ R oved
n. o ft.❑Perforated 171Removed
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_
2
Z
\
D
of Perforator
ype
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes [7kNo TN# �^
GROUTING MATERIAL(S)
Grouting Material0' V �� from 0 to Z5 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
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is true to the best of my knowledge.
E N N I S
Licensee B iness Name License or Registration No.
T 114,{ 34, 0) 1/23u�0) 1�2bl��
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Certified Representative Signature Certified Rep. No. Date
000LEVY
IMPORTANT-FILE WITH PROPERTY
PAPERS-WELL OWNER COPY
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a e of Person Sealing Well or Boring
HE -01434-17 ID# 53159 1 N 11/198
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