HomeMy WebLinkAbout04-11-2022 Well & Boring Sealing RecordWell and Boring ' I :J
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota C� B ^i , j 5
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. C�
Minnesota Statutes, chapter 1031 or-s�e9ies No.
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Township a e
Township No.
Range No.
Section No.
Fraction (sm. -+ Ig.)
Date Sealed
Date Well or Boring Constructed
GPS LOCATION - decimal degrees (to four decimal places)
Depth at Time of Sealing 8 7 ft.
Original Depth ft.
Latitude Longitude
AQUIFER(S)
Pq Single Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
) t ! / �f
� Measured Date Measured 1.1 J 2 2 ❑ Estimated
6 2 [Xbelow El above land surface
Numerical Street Address or Fire Number and City of Well or Boring Location
1525 Minnie Ave "Ipund rPT 55361%
W ELLBORING
Water -Supply Well Env. Well
❑ Tem Boring Other
p 9 ❑
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.
CASING TYPE(S)
KI Steel ❑ Plastic ❑ Tile ❑ Other
--;--- --�--- ---r-----�--. _ -•
WELLHEAD COMPLETION -
W-- - --. -
I f
'k Mile
1
Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: Basement Offset
El Well Pit E] Buried Well House
EJ Well Pit
❑ Other
❑ Buried
I— —t Mlle
❑ Other
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.
CASINGS)
Diameter Depth Set in oversize hole? Annular space'initially grouted?
2 In. from 1 to 8 3 ft. ❑ Yes ❑ No ❑ Yes ❑ No [Unknown
PROPERTY OWNER'S NAME/COMPANY NAME
?Kari. DuenQW
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
Property owner's mailing address if different than well location address_ Indicated above
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
Screen from__8 3 to � 7 ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
lk Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owners mailing address If different than property owner's address Indicated above
Type of Obstructions (Describe) drop 1:D+>
Obstructions removed? EkYes ❑ No Describe
PUMP
❑ Not Present ® Present, Removed Prior to Sealing ❑ Other
Type- jP F ) I I rn t)
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
E*No Annular Space Exists ❑ Annular Spare 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 ® No TN#
GROUTING MATERIAL(S)
Grouting Material Neat Cement from 1 to 87ft._yards 2 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
is true to the best of my knowledge.
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
non !:;t'o,jol i Nal m i l l ink rn Inc 1691
Licensee Business Name License or Registration No.
/,f / //� 55`� !,/1�,M
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Certi#ed.l' 06sentative Signature ` Certified Rep. No. Date
Jerry Barr
LOCAL COPY H i )H
Name of Person Sealing Well or Boring
HE -01434-17 ID# 53169
11/19R