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HomeMy WebLinkAboutwell info 1/11/24 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well Boring 4 O 7730 WELL OR BORING LOCATION Sealing No. H W ELL AND BORING SEALING RECORD •County Name Minnesota Unique Well No. 4; lEN EPIN Minnesota Statutes,chapter 1031 or W-series No. (Leave dank if not known) Township Name Township No. Range No. Section No. Fraction(sm.-lg.) Date Sealed Date Well or Boring Constructed ©RONO . 117 23 10 SE'SE W ', 1/11/2024 GPS LOCATION-decimal degrees(to four decimal places) 173 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 fe Single Aquifer ❑Multiaquifer 1245 LAKEVIEW AVE. :WAYZATA.4N WELL/BORING X Measured Date Measured 1/11/2094 Estimated ®Water-Supply Well ❑Env.Well 52 Show exact location of well or boring ,,.553 Sketch map of well or boring in section grid with"X." ocation,showing property ❑Temp.Boring ❑Other ft. below ❑above land surface N r • lines,roads,and buildings. CASING TYPE(S) a C VftAVE:4 VE, [.Steel ❑Plastic ❑Tile ❑Other WELLHEAD COMPLETION w E{ . TOutside: C Pitless Adapter/Unit El At Grade Inside: ❑Basement Offset { I Mile Well Pit ❑Buried ❑Well House �---t --T-- 1.- 1 S I Well Pit `- ❑Other ❑❑Buried :..r 1- 1 Mile { A ❑Other For temporary borings,provide additional location • CASING(S), information,a site sketch,and geology on a separate page. Diameter/ • Depth Set in oversize hole?. Annular space initially grouted? PRJP. A kil RR'SSNAM�tE OMP NY NAME 4 in.from I to 165 ft. ❑Yes ❑No ❑Yes ❑No g Unknown Property jjojjwner'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 1 SCREEN/OPEN HOLE, I Screen from 1 V 5 to 173. ft. Open Hole from to ft. WELL OWNER'S NAME/COMPANY NAME J --•- -- - f ENNIFER NORD OBSTRUCTIONS .- gr ,.- v + k' .ti. , . Well owner's mailing address if different than property owner's address indicated above I Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction ' DROP PIPE ) Type of Obstructions(Describe) l Obstructions removed? 1 Yes ❑No Describe PUMP ( GEOLOGICAL MATERIAL_ COLOR HFORMATI oR FROM TOORMATION ❑Not Presentreseennt ®Present,Reemooved Prior to Sealing ❑Other If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE DRIFT 1. 173 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE - ZJ 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 1 173 14 - Grouting Material from to ft. yards bags 'ti from to ft. yards bags l,. 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 i is true to the best of my knowledge. - 1 I. ,t, - ,1 - i : ? .- DON �r.�ryy'� x WELL 1. t- _ .: a31ODOLA` TN Li'L.ia CDRILLING .r . INC. 1691 - - i:. Licensee Business Name ' License or Registration No. f - 558 1/11/2024 i; . C ifpd'Representative Signature Certified Rep.No. Date W' r} LOCAL COPY H 4 07730 .Name of Person Sealing Well or Boring HE-01434-17 ID#53159 - 11/19R