HomeMy WebLinkAbout09-15-22 well & boring sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 397016
County Name WELL AND BORING'SEALING RECORD Sealing Na Unique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
y y jy y^..j� P (Leave blank,f not known)
Township Names Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed
OiCuSIUU 117 23 U4 A AWSE '' 9/15/22
GPS LOCATION—decimal degrees(to four decimal places) 109
Depth at Time of Sealing ft. Original Depth ft.
Latitude... Longitude
AOUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location [Single Aquifer ❑Multiaquifer
Y WELL/BORING 3 Measured Date Measured 9/15/22 ❑Estimated
t7uU ftlTh UA1� CIRCLE„ �i��}I�IU, Water-Supply Well El Env.Well
Show exact location of orfrib1ial S'b Sketch map of well or boring
in sebtion grid with"X. location,showing property LI Temp.Boring ❑Other 51 ft. [Ibelow ❑above land surface
I' a ,roads,and buildings.N CASING TYPE(S)
,. Al Steel ❑Plastic ❑Tile ❑Other
•--___ --•--- --- WELLHEAD COMPLETION
w ET
____ I Outside: ®Pitless Adapter/Unit El At Grade Inside: El Basement Offset
h Mile ❑Well Pit ❑Buried ❑Well House
-- --- i r --- I ❑Well Pit
I i 1 r( ❑Other s
❑Buried
1 Mile ❑Other
For temporary borings,provide additional location . CASING(S)
information,a site sketch,and geology-On a separate age. Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME / in.from to 1 05 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown
LUS T Ur ONE AUAES, LLU 7'`
Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
bSt rIUEMliEitG f1i #103 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WOODBUSY, 4N 55125
SCREEWOPEN HOLE
Screen from 1 05 to 109 ft. Open Hole from to ft.
WELL OWNER'Syy� NAME/COMPANY NAME !�
C0 iUA UNE Lce AA S, LLC OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above A Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
DROP PIPE
Type of Obstructions(Describe)
Obstructions removed? 4Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present�t Present,Removed Prior to Sealing ['Other
If not known,indicate
10
iindicate estimated formation log from nearby well or boring. i �q Type SUBMERSIBLE
DR/i ♦ 1 9 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
[A 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 A No TN#_
GROUTING MATERIAL(S)
svi AT CEMENT 1 109 9
Grouting Material from 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 EI 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.
DOA STUDGLA WELL Cu 1691
Licensee Business Name License or Registration No.
,,� ,� 55t3 9/15/22
- ur . f
e epresentative Signs ure Certified Rep.No. Date
JER RY 13ARR
LOCAL COPY H 3 9 7 016 Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R