HomeMy WebLinkAbout11-22-2023 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I
County Name WELL AND BORING SEALING RECORD Sling M nneso aoUnique Well No. -
` Minnesota Statutes,chapter 1031 or W-series No.
P {Leave blank if nod known)
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Township Name Township No. Range No. Section No. Fraction(sm.— lg.) Date Sealed Date Well or Boring Constructed
Ott Oil 0 117 23 04 A i,v ioj 4.6 % 11/22/22
GPS LOCATION—decimal degrees(to four decimal places) bb
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 a Single Aquifer ❑Multiaquifer
2760 C O N , .S S I D E R.w. 'L O iy WELL/ A Measured Date Measured 1 1/�2 2/2 2 ❑Estimated
11 Water-Supply Well ❑Env.Well
Show exact location of well or boring/ALL g�1t sq pi wwyy ��pq g
in section grid with"X." Rr Ideal- shAITfg l ftyn ❑Temp.Boring ❑Other b 7 ft. ®below ❑above land surface
lines,roans,and buildings.
N CASING TYPE(S) .
, ❑Steel AI Plastic ❑Tile ❑Other
/ ,.
WELLHEAD COMPLETION
. I-------T__ Outside: X Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
Mil ❑Well Pit ❑Buried ❑Well House
, — r . -
❑Well Pit
❑Other
S ❑Buried
I-1 Mile
❑Other
For temporary borings,provide additional locati CASING(S) -
nformation,a site sketch,and geology on a seta to page. Diaeter Depth? Set in oversize hole? Annular space initially grouted?
PRRPPFTY /NER' fA[ EOr .�4Yt1VP/) in.from I to ft. ❑Yes ❑No ❑Yes ❑No A 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
Screen from 177 to 186 ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME .
J ON Mt ivioLli if S. E k ii OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above IX Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
PIPE ,
Type of Obstructions(Describe) '
Obstructions removed? Lj 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. S U8 &S BLE
Type
DRIFT1 112 METHOD 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 ❑No TN#
GROUTING MATERIAL(S)
NEAT Grouting Material C t �d`t from to 1
186 ft. yards 16 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.
DON 0 1 L WELL DRILLING CO. 1691
Licensee Business Name License or Registration No.
/ , 558 11/22/22
Certified Representative Signature Certified Rep.No. Date
H JERRY BARK
LOCAL COPY 3 9E O Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R