HomeMy WebLinkAboutWell & Boring Sealing RecordMINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 413688
WELL OR BORING LOCATIONSealing
WELL AND BORING SEALING RECORD Minnesotta Unique Well No.
County Name
HEN NE PI NY Minnesota Statutes, chapter 1031 orr„ -series No,
Township Name Township No, Range No. Section No. lFraction (sm. - Ig.) Date Sealed Date Well or Boring Constructed
OR0110 117 23 10 4d`P WNW '� 11/12/24
GPS LOCATION — decimal degrees (to four decimal places)
Depth at Time of Sealing 67 it. Original Depth ft.
Latitude Longitude
AQUIFERS) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer ( i / 1 ry / 2
660 BROWN E� . a • W i �+ ! . WELUBORING �] Measured Date Measured ! i G ❑Estimated
Q Water -Supply Well ❑ Env. Well
Show exact location ottw I r' ing Sketch map of well or boring
in section grid with "X- location, showing property ❑Temp, Boring ❑Other t( ff. ]below ❑above land surface
N lines, roads, and buildings. CASING TYPE(S)
W
E
Steel ❑ Plastic ❑ Tile ❑ Other
WELLHEAD COMPLETION
T
Outside: ❑ Pitiless Adapter/Unit ❑ At Grade Inside: Basement Offset
'h Mile ❑ Well Pit ❑ Buried
El Other Well House
❑ Well Pit
1
s ❑Buried
)-1 Mile 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?
Pf;pgE€4TY pWWER' iy CgMPANY NAME 4 in. from 1 to n 5 7 ft. El Yes ❑ No El Yes El No 1Z] 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
SCR EE WOPEN rHHOLLE
Screen from .7 7 to f�ft. Open Hole from io tt.
WELL OWNER'S NAME/COMPANY NAME
}O�BSTRUCTIONS
Well owner's mailing address if different than property owner's address Indicated above u Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ FIII ❑ No Obstruction
Type of Obstructions (Describe) d Cb p pipe
Obstructions removed? ® Yes ❑ No Describe
PUMP
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present CJ Present, Removed Prior to Sealing ❑ Other
FORMATION ❑
If not known, indicate estimated formation log from nearby well or boring. Type ubme r s i b 1 e
drift 1 67 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
n 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 1P No TN#
GROUTING MATERIAL(S) tt
Grouting Material neat CemF nt from .! to (7 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 K] 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.
1)0iN `,T')DO A '01:1,1T ngu jjT4 -c-4 , i_N 16�I
Licensee Buslne Name — Licens!? or Registration No.
1691 11/20 247,
Certified Representative Signature Certified Rep. No. Date
.Jerry Ilarr
LOCAL COPY H 413688 Name of Person Sealing Well or Boring
H E-01434.17 ID# 53159 1 f /1 sR