HomeMy WebLinkAbout09-30-22 Well & Boring Sealing Record •
WELL OR BORING LOCATION Sealing No.
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„� g 6 g 9
County Name WELL AND BORING SEALING RECORD MinnaoUnique Well No.
j�` ' a Minnesota Statutes,chapter 1031 or W-series No.
j ,[ (Leave blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed
O O OO 117 23 07 S SE'S " /30/22
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 0 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location DI Single Aquifer ❑Multiaquifer t ;fi
4041 A d • . i7 S ri E DRIVE, °R o o s WELUBORING Measured Date Measured /], /22 ❑Estimated
A Water-Supply Well ❑Env.Well
Show exact location of well or boring Ali .) )..ititeii map of well or boring 44
in section grid with"X" location,showing property ❑Temp.Boring ❑Other ft. 0 below ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
y
A Steel ❑Plastic ❑Tile ❑Other
-` `-- WELLHEAD COMPLETION
W E
- T Outside: li Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
I
'k Mile ❑Wet Pit ❑Buried ❑Well House
i ❑Other ❑Well Pit
s ❑Buried
f —t Mile --1
❑Other
For temporary borings,provide additional location 4.I CASING(S)
information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted?
PR a O R' P.NY_LI E,.,, , in.from to ft. ❑Yes ❑No ❑Yes ❑No 4 Unknown
Propertygq owner's mailing address if differenti than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1 3 2 IN,€i,i;rTOSK1 LVD
-f in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
' SCREEN/OPEN HOLE
WELL OWNER'S NAME/COMPANY NAME 86
Screen from to ft. Open Hole from to ft.
DAVID BILLtit OBSTRUCTIONS
Well owner'sr' mailing address if different than property owner's
address indicated above A Rods/Drop Pipe ❑CheckgValve(s) y�❑Debrisi ❑Fill ❑No Obstruction
1729 l G,�w#�1ii. & POINT R DROP PIPE
Type of Obstructions(Describe)
° O' )* MN 55391
Obstructions removed? 111 Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARQNESS OR FROM TO
FORMATION ❑Not Present QPresent,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE
Li RI P3 11 1 tit) METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
.F]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)NEAT�a CEMENT T 1 86 7
Grouting Material from to ft. yards ._ bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS i
Other unsealed and unused well or boring on property? ❑Yes A 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.
..t. iA S O OLA WELL CO 1 b I
Licensee Business Name License or Registration No.
--2,/'-.5(,
,
9/30/22
F/ - ir ' 558
Cerrtifiedihepresentative Signature Certified Rep.No. Date
LOCAL COPY H g 6 98 g ,BERRY B R R
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R