HomeMy WebLinkAbout12-27-22 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 9 9 I )
SCounty Name WELL AND BORING SEALING RECORD M nnlesotaoUnique Well No.
• Minnesota Statutes,chapter 1031 or W-series No.
;{ N�'w IJ$ 4`• p (Leave blank if"known)
Township Name •F Township No. Range No. Section No. Fraction(sm.—,lg.) Date Sealed
Date Well or Boring Constructed
QIWNU 117 23 17 SW S*PI 4,14 12/2/f 2
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 117 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 ❑Multiaquifer19 �terr'''' ryr� p /
�' s POINT r r LUBORING Li•+rneasured Date Measured 1 d.J 2 7/ 2 2 ❑Estimated
:i:Water-Supply Well ❑Env.Well
Show exact location of well or boring',ii • 5 map of well or boring 54
in section grid with"X." ron,showing property ❑Temp.Boring ❑Other ft. ]below ❑above land surface
roads,and buildings.
N CASING TYPE(S)
/gl Steel ❑Plastic ❑Tile ❑Other
T ` ''' WELLHEAD COMPLETION
W E 4
__�___. T__- T ., Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: A Basement Offset
'k Mile r ❑Well Pit ❑Buried ❑Well House
I-- • ' . ❑Well Pit
• s c,� ❑Other
❑Buried
1-1 Mile I ,,
...,,,'fir � ❑Other
For temporary borings,provide additional location CASING(S)
E° information,a site sketch,and geology on a separate page. Di eter De th + Set in oversize hole? Annular space initially grouted?
P s�P► 1 t� �L Elp NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Property owner's mailing address it 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
WELL OWNER'S NAME/COMPANY NAME Screen from 1 13 to 117 ft. Open Hole from to ft.
SLAIN , P i .RSON OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above N Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) drop pipe
•
Obstructions removed? llrYes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Nat Present [Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type jet pump
drift 0 117 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
X 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 No TN#
GROUTING MATERIAL(S) Cement
Grouting Material Neat from 1 to 1 1 7 ft. yards 5 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 r 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 ST D LA WELL DRILLING O. ,I C. 1691
Licensee Business Name License or Registration No.
{ . 12/28/22
Clhitifiecd Representative Signature Certified Rep.No. Date
LOCAL COPY H 3 9 3 2 Jerry Barr
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R