HomeMy WebLinkAbout06-14-2022 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota
N Well and Boring H 3 C 5 1 11
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
/�
Minnesota Statutes,chapter 1031 or W-series No.
Tennep i n (leave blank it not known)
CerRA-'^/ Township No. Range No. Section No. Fraction(sm.—r lg.) Date Sealed Date Well or Boring Constructed
AftVaTTt 117 23 20 SE'ASE N 6/14/22
GPS LOCATION—decimal degrees(to four decimal places)
1
Depth at Time of Sealing ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location X]Single Aquifer ❑Multiaquifer 6/14/22
+
2700 Cosco Rd, Navarre CG�iA ELL/BORING Measured Date Measured 6/ 4/ ❑Estimated
G LI Rd !,r PtJ J 3 Water-Supply Well ❑Env.Well
Show exact location of well or boring Sketch map of well or boring 76
in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. below ❑above land surface
lines,roads,and buildings.
N CASING TYPE(S)
•«K- X Steel ❑Plastic ❑Tile ❑Other
'--'--- ---'--- jR�, WELLHEAD COMPLETION
w - ET te'
Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: X Basement Offset
j Mile f Well Pit ❑Buried WellHouse
hPill
❑❑
s I V Pit
1 ❑
Well
) i ill Other
I Buried
1 Mile
at ❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. Diameter Depth
Set in oversize hole? Annular space initially grouted?
PriiiTYYVIVARi itiAECOMPANY NAME 2 in.from 1 to f O/ 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
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEN/OPENHOLEE�
Screen from 107 to 111 ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above IX Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)
Rod8
Obstructions removed? gYes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present A Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type stroke pump
drift 0 111. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
,[J No Annular Space Exists ❑Annular Space 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 2]No TN#
' GROUTING MATERIAL(S) �+
Grouting MatL�rral Neat Cemen yy from 1 to 111 , yards 3 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 X No 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.
Don Stodola well Drilling Co 1691
Licensee Busines ame License or Registration No.
558 6/14/22.
Ce dfert ed Representative Signature Certified Rep.No. Date
Jerry Barr
LOCAL COPY H .) (I 1 1 1�- -�- --� .�r.. Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R