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HomeMy WebLinkAboutwell and boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 4 0 8 8 0 3 R BORING LOCATION SWELL AND BORING SEALING RECORD Minnesota lNo.Unique Well No. HENNEPI N Minnesota Statutes,chapter 1031 or W-series No. (Leaoe dank,t not known) Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed 1N0 117 23 07 $W'1 SW SM 3/20/2024 ATION—decimal degrees(to four decimal places) Depth at Time of Sealing 116 ft. Original Depth ft. e Longitude AOUIFER(S) STATIC WATER LEVEL Street Address or Fire Number and City of Well fopr Boring gtLoocation [Single Aquifer LI Multiaquifer (It (Q REST POINT RD.;t-i©4AL�f WELL/BORING Measured Date Measured 3/20/24 ❑Estimated j]Water-Supply Well ❑Env.Well 46 ct location of well or boring 5536/,Sketch map of well• .oring Tem Boring with"X" ocation,showin. .operty ❑ p LI Other ft. [)below ❑above land surface N lines,road : .buildings. CASING TYPE(S) ' \ [ISteel ❑Plastic ❑Tile ❑Other --' ---`------'--- °} WELLHEAD COMPLETION E ' T Outside: [ Pitless Adapter/Unit LI At Grade Inside: LI Basement Offset 'h Mile ❑Well Pit ID Buried LI Well House 1 )l ❑Other ❑Well Pit S ❑Buried t Mile---I ❑Other nary borings,provide additional location CASING(S) in,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? EYOWNER'S NAME/COMPANY NAME 4 in.from 1 to 108 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown 'RO HOMES vner'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 SCREEWOPEN HOLEp INER'S NAME/COMPANY NAME DOBLIN y� Screen from 108 to 116 ft. Open Hole from _ to ft. :ENE & GALINA DOBLIN OBSTRUCTIONS 's mailing address if different than property owner's address indicated above L3 Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill LI No Obstruction - DROP PIPE Type of Obstructions(Describe) Obstructions removed? [I'es LI No Describe PUMP IGICAL MATERIAL COLOR HARDNESS OR FROM TO FORMATION ❑Not Present gi Present,Removed Prior to Sealing El Other wn,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE FT 1 116 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 LI 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 7IU No TN# GROUTING MATERIAL(S) �+ Grouting Material NEAT CEMENT from 1 to1.16 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 C No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION S,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 WELL DRILLING CO. ,IHC, 1691 Licensee Business N me License or Registration No. 558 3/20/24 ert.d epressentativeSignature Certified Rep.No. Date LOCAL COPY El4 0 88 0 JERRY BARB Name of Person Sealing Well or Boring -17 ID#53159 11/19R