HomeMy WebLinkAbout01-05-23 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring (r 1 .
WELL OR BORING LOCATION Sealing No. H 3 c' 2
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
�t Minnesota Statutes,chapter 1031 or W-series No.
Sad`ttt >4r';r (Leave blank if not known)
r Township Name YF Township No. Range No. Section No. Fraction(sm.-w lg.) Date Sealed Date Well or Boring Constructed
0R(TO 117 2 05 SEES; ,/, 1/5/23
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 144 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 ❑Multiaquifer
33r0 + : , g]Measured Date Measured 1 I' 2
t WELL/BORING ❑Estimated
®Water-Supply Well Li Env.Well
Show exact location of well or boring 55356 Sketch map of well op5oring 22
in section grid with"X" location,showing p�o perty ❑Temp.Boring ❑Other ft. IX below ❑above land surface
lines,roads,a t5uildings.
N ( s CASING TYPE(S)
)( A Steel ❑Plastic ❑Tile ❑Other
WELLHEAD COMPLETION
w EI
Outside: A Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
h Mile , ❑Well Pit ❑Buried ❑Well House
- ---.- 1 .�..''''''')
❑Other ❑Well Pit
s ❑Buried
I——1 Mile { g -- »» � w` ) ❑Other
f
For temporary borings,provide additional locatio? CASING(S) .
information,a site sketch,and geology on a separ ge. _Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME 4 4 in.from to ft. ❑Yes ❑No ❑Yes ❑No Unknown
Li
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
SCREEWOPEN HOLE
Screen from 136 to 144
ft. Open Hole from to ft.
WELL OWNERS NAME/COMPANY NAME
W I LLIJA `''RUBECk OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above g Rods/Drop Pipe ❑Check Valve(s) ['Debris ❑Fill ❑No Obstruction
DROP PIPE
Type of Obstructions(Describe)
Obstructions removed? g Yes ❑No Describe
PUMP
HARDNESS OR
GEOLOGICAL MATERIAL COLOR I FORMATION FROM TO ❑Not Present [X Present,Removed Prior to Sealing ❑Other
If noty known,indicate estimated formation log from nearby well or boring. Type
DRIFT F,#, SUBMERSIBLE
1 144 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)
NEAT CEMENT 1 144 12
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.
L.ON STu OLA WELL DRILLING CO• ,INC. 1 b91 a
Licensee Business =me License or Registration No.
," 1/5/23
`Cert'red Representative'Signature . Certified Rep.No. Date
JERRi BARB
LOCAL COPY H ' Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R