HomeMy WebLinkAbout09-30-22 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' .
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SealinCounty Name WELL AND BORING SEALING RECORD MinnesotaeUnique Well No. [�
t Minnesota Statutes,chapter 1031 or W;a eries No.
hEANTownship Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed
RO O 117 23 00 6 S ISE"4 9f 30, 21.
GPS LOCATION—decimal degrees(to four decimal places) �1:i 2 0
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 ®Single Aquifer ❑Multiaquifer /� }i,.
775 LAK 1 V I L PARKWAY, R O, =,yX/4 WELL/BORING [ Measured Date Measured J i ' ❑Estimated
I. [Water-Supply Well ❑Env.Well
Show exact location of well or boring .7.) Sketch map of well or boring t
in section grid with"X." location,showing property ❑Temp.Boring ❑Other 5- ft. ®below ❑above land surface
lines,roads,and buildings.
CASING TYPE(S)
- . '_ ❑Steel ®Plastic ❑Tile ❑Other
i
"-'1-------,-- WELLHEAD COMPLETION
W ETOutside: Q Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
❑Well Pit ❑Buried ❑Well House
__________1
❑Other ❑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. Dia13neter , , Depth Set in oversize hole? Annular space initially grouted?
PRorpFvoyogR'S NAME/COMPANY NAME 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
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEN/OPEN HOLE
116 126
!)1E/C,CIf�i�t,El P, E Screen from to ft. Open Hole from to ft.
WE L
ai r OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill A No Obstruction
Type of Obstructions(Describe)
Obstructions removed? ❑Yes ❑No Describe '
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION [ Not Present ❑Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type
DRIFT 1 126 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 I No TN#
GROUTING MATERIAL(S)
NEAT AT CE.AINT 1 126 11
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.
ie$1. LE DUN S'r . OIJA WELL COT O 91
Licensee Buesy Name License or Registration No.
-Certified Representative Signature Certified Rep.No. Date
LOCAL COPY H Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R