HomeMy WebLinkAbout04-21-2023 Well & Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota
toN Well and Boring H 400061
SealingCo ty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,chapter 1031 or W-series No.
EA EF I (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-lg.) Date Sealed 2
RJ Date Well or Boring Constructed
'O O 118 23 3 ? SWSWSW'/4 / .i
GPS LOCATION—decimal degrees(to four decimal places)
Depth at Time of Sealing 133 ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location 1]Single Aquifer ❑Multiaquifer / /
15 nY RTL O0 RD. , g- O N fez• WELL/BORING �]Measured Date Measured 4 L 2 1 f 2 ❑Estimated
i1 V�# +4! 4# 1:1 Water-Supply Well ❑Env.Well
Show exact location of well or boring 5539 1 Sketch map of well boring 69
in section grid with"X." showing pr erty ❑Temp.Boring ❑Other ft. ]below ❑above land surface
lines,r ds,and bui s.N CASING TYPE(S)
u
X Steel ❑Plastic ❑Tile ❑Other
----- -----------I---I--- WELLHEAD COMPLETION
w E T•
-- I Outside: ❑Pitless Adapter/Unit Li At Grade Inside: El Basement Offset
h Mile ❑Well Pit -Buried ❑Well House
---I- -
--- ❑Well Pit
1 ❑Other
s ❑Buried
1 Mile
VV. ❑Other
aldkl For temporary borings,provide additA )V N)) . CASING(S)
information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted?
P. O ERT. WNER'S NAME/COMPANY NAME 4 1 to 129 ft,� ,t,' in.from ❑Yes ❑No ❑Yes ❑No �]Unknown
Property owner's mailing address if different 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 to ft. Open Hole from to ft.
WELL OWNER'S NAME/COMPANY NAME
T/C AiOL UNGS OF t ,AINE LLC OBSTRUCTIONS
Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
13501 BALSAME LA Type of Obstructions(Describe) DROP PIPE
DA a ON, MN. '"55327
Obstructions removed? X Yes ❑No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present ®Present,Removed Prior to Sealing ❑Other
FORMATION ❑
If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE
DRIFT 1 133 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 g No TN#
GROUTING MATERIAL(S)NEAT CEMENT 1 133 10
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 41 No How many?
LICENSED OR REGISTERED CONTR/iCTOR 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. �roa
DON STODOLA WELL DRILLING CO. ,I C* 1691 .
Licensee Rusin s ame License or Registration No.
558 4/21/23
e e Representative Signature Certified Rep.No. Date
LOCAL COPY H 400061 JERKY BARK
Name of Person Sealing Well or Boring
HE-01434-17 ID#53159 11/19R