HomeMy WebLinkAbout01-31-23 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
H
WELL oR BORING LocarloN WELL AND BORING SEALING RECORD Sealing No. �14
CountyName Minnesota Unique Well No.
AENNEPIN q
Minnesota Statutes,chapter 1031 ONO or W series No.
,f (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.—lg.) Date Sealed Date Well or Boring Constructed •
1,,t •j LA&E 116 23 33 SOSENL '/^ 1/31/23
GPS LOCATION— decimal degrees(to four decimal places)
Depth at Time of Sealing .U 1 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address r Fire.Number and City of Well or Boring Location IX Single Aquifer El Multiaquifer
if�(� ®Measured Date Measured £ L f j ❑Estimated
3 ct KA ....e St' i 1�/ WELLBORING Water Supply Well ❑Env.Well
Show exact`o6Micin of-weft-crh 6" - -- p vf.well_oC.,la ri3O" 50 in section grid with"X." owing property ❑Temp.Boring ❑Other ft. below ❑above land surface
N _<, ,. <; ," ,and build gs. CASING TYPE(S)
1
❑Steel X Plastic ❑Tile ❑Other
lj fr r-
--------------•---`------f--- WELLHEAD COMPLETION
W ET r
1 r" Outside: III Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
it'
- ' Mile 4:.+ ❑Well Pit ❑Buried ❑Well House
---; T ,-
i"" ❑Well Pit
s ❑Other
❑Buried
1 Mile
f ❑Other
For temporary borings,provide additional location CASING(S)
information,a site sketch,and geology on a separate page. I Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from I to 15 7 ft. ❑Yes ❑No ❑Yes ❑No zo Unknown
BOB ERICKSON
Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
2435 lltAYZATA L LVD I
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
LONG LA i ,r AN. 55356SCREEN/OPEN HOLE
157 r
Screen from to ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
OTC° PROPERTIES INC OBSTRUCTIONS
Well owner's mailing address if differentr► than property owner's address indicated above ®Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
2435 WAYZA#A BLVD R Type of Obstructions(Describe)DROP PIP
LONG LAKE, AA. 55356
Obstructions removed? x Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present I Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE
DRIFT 1 161 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
®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 F]No TN#
GROUTING MATERIAL(S)
NEAT CEMENT T 1 161 16
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 Fl No How many?
i LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
1 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 .
iis true to the best of my knowledge.
il�O SIOD LA t L1 tam . , x 10 1
( Licensee Business,Nameev License or Registration No.
--,e;?.?" ,, ,::"":,: --e-c----/.,1:. ' :::,;;.,..4-- -:— 1/31/23
ertrtied representative Signature Certified Rep.No. Date
c
JMUX B A R
H CI '1 /I i
LOCAL
COPY Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 t i/19R