HomeMy WebLinkAbout10-06-2022 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 9 9 9
No.
County Name WELL AND BORING SEALING RECORD MinnSealiesota Unique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
IILNNEP/N (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.—+Ig.) Date Sealed Date Well or Boring Constructed
O t ,3 117 2 1u s' 4 W'Ni ,4 10/ 6/L2
GPS LOCATION—decimal degrees(to four decimal places)
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 r Single Aquifer ❑Multiaquifer qf�
WELLB 1ORING [2 Measured Date Measured U/ C)/2 2 ❑Estimated
�-h4 iiENCtit LAAL RD., OROAO„ N
il Water Supply Well ❑Env.Well
Show exact location of well or boring 35 391 Sketch map of well or boring f,
in section grid with"X." location,showing property ❑Temp.Boring ❑Others, 4-1 ft. [j below ❑above land surface
lines,roads,and buildings. CASING TYPE(S)
N I I L
Steel ❑Plastic Tile ❑ ther
-1 ,-J__ __I I__ — ri
WELLHEAD COMPLETION
w E T L 0Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: 4Basement Offset
'h Mile ❑Well Pit ❑Buried ❑Well House
f
_, ,_ _ i ❑Other III Well Pit
s ❑Buried
1 Mile
_..__.-
❑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?
PROPERTY OWNERS NAME/COMPANY NAME 4 in.from I to 2 56 ft. ❑Yes ❑No ❑Yes ❑No 1 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/OPEN HOLE
NAME
Screen from 258 to 268 ft. Open Hole from to ft. i
WELL OWNER'S NAME/COMPANY
A LL A J OAiN.S 1.W OBSTRUCTIONS
Well owner'st's mailing address if different than property owner's address indicated above ®Rods/Drop Pipe ❑Check Valve(s) ❑Debris El Fill ❑No Obstruction
f T.u. I . b 4 142 Type of Obstructions(Describe) DROP PIPE
ST. PAUL, AN. 5 /04
Obstructions removed? 1.Yes ❑No Describe
PUMP '
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present 4 Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type S Uf 1.:e B R a S LE
DRIFT IF •�I ,,�;,> d METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
M No Annular Space Exists LI 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 X]No TN#
GROUTING MATERIAL(S) .
NEAT CE LNT I 2c6 24
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 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 STO1OLA WELL CO 1691
Licensee Business Name License or Registration No.
,,,,,,,,;>/:„.„ex:47,- .„.
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY H 9 J'R R Y A R R
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R