HomeMy WebLinkAbout01-26-2023 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H„� `) f ` q
WELL AND BORING SEALING RECORD Sealing No. i ,�
County Name Minnesota Unique Well NO.
Minnesota Statutes,chapter 1031 or W-series No.
it EisitiEFIA (Leave blank if nol known)
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed
ORO > 117 2: 07 SE'SESE ''° 1/26/23
GPS LOCATION— decimal degrees(to four decimal places)
145
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 / ,.
Measured Date Measured 1 12 0/2
4 U U&T O £ uV , live WELLBORING ❑Estimated
ie A Water-Supply Well ❑Env.Well
Show exact location of well or borirkiki 553 f;fijetch ma of wel r boring
in section grid with"X" location,sh ing i'operty ❑Temp.Boring ❑Other 71 ft. X below ❑above land surface
lines oads, u ings.
N `� CASING TYPE(S)
!, r Steel ❑Plastic ❑Tile ❑Other
------ ` ` WELLHEAD COMPLETION
W E
T ",,a4 t Outside: A Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset
Mile ❑Well Pit ❑Buried ❑Well House
_ ❑Other E]Well Pit
S ❑Buried
I 1 Mile tN
❑Other
For temporary borings,provide additional location= CASING(S)
information,a site sketch,and geology on a separate pag Diameter Depth Set in oversize hole? Annular space initially grouted?
PROPERTY OWNER'S NAME/COMPANY NAME �i in.from to j ft. ❑Yes ❑No ❑Yes ❑No ]Unknown
J0k EL ^�RE
Property owner's mailing address if different than well locatio eddress indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
SCREEN/OPEN HOLE
137 14
WELL OWNER'S NAME/COMPANY-NAMEScreen from to ft. Open Hole from to ft.
JOHN E . ORE OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above gi Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
DROP PIPE
Type of Obstructions(Describe)
Obstructions removed? ❑Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO
FORMATION ❑Not Present A Present,Removed Prior to Sealing ❑Other
If not known,indicate estimated formation log from nearby well or boring.t� Type S ki''i}` R S I iLk.
Lit R I �`�, 1 14 5 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
4f 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)
SEAT CEMENT 1 145 13
Grouting Material from to ft. yards bags
from to ft. yards bags
fr�tai 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 STODOLA WE.rLLDAILLI 4G CO. , INC. 1691
Licensee Business Name License or Registration No.
' 1 26 f 2;
/' '
d Representative Signature S Certified Rep.No. Date
JERRY BARR
LOCAL COPY H Q
-` ,,, `, _ Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R