Well Sealing Record 3-11-25 - Laserfiche WebLink

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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring- EI 415615 ' WELL-OR BORING LOCATION Sealing No. r, county Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. 8 NN. P I N Minnesota Statutes,chapter 1031 or W-series No. i - (Lease dank t nd known) , :; T hi a Township No. Range No. Section No. Fraction sm.-.lg.) Date Sealed Date Well or Boring Constructed 117 23 03 s ,W5 3/11/2025 GPS LOCATION-decimal degrees(to four decimal places) Latitude Longitude Depth at Time of Sealing 195 ft. Original Depth ft. AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location 1 Single Aquifer ❑Multiaquifer WELL/BORING Measured Date Measured 3/1 1/2 5 CI Estimated , 2285 WEBBER HILLS RD. WAYZATA -II®Water-Supply Well ❑Env.Well. Show exact location of:'r@ or 65i56391 Sketch map of well or boring C in section grid with"X" • •location,showing property ❑Temp.Boring ❑Other 5 5 ft. 1 below ❑above land surface lines,roads,C^ and buildings. :. N {^ �? CASING TYPE(S) i' lil Steel ❑Plastic ❑Tile ❑Other _------'----- - t _ WELLHEAD COMPLETION II . . Outside: C!Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset T h Mile ❑Well Pit ['Buried ❑Well House ❑Other I]Well Pit s ❑Buried I 1 Mile • t' k * 7 ❑Other f, For temporary borings,provide additional Iocatid) ` - _'- - CASING(S) information,a site sketch,and geology on a separate page. , b.1 Diameter Depth ' Set in oversize hole? Annular space initially grouted?' Firarijer gNEIIS N O ANY ilbasoN 4 in.from 1 to 187 ft. ❑Yes ❑No 0 Yes El No ii]Unknown Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes El No '"No . Q Yes ❑No ❑Unknown I: in.from to ft.;) CI Yes= ;❑No ❑Yes ❑No ❑Unknown ' SCREEWOPEN HOLE - , 4 ,....1 ' t Screen from 1 8 7 to 1 A 5 ft. Open Hole from to ft. - WELL OWNER'S NAME/COMPANY NAME _ c .- - .,,. OBSTRUCTIONS ' _ - i Well owner's mailing address if different than property owner's address indicated above ®Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction • Type of Obstructions(Describe) DROP PIPE i Obstructions removed? [ ,Yes ❑No Describe ' PUMP HARDNESS OR GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Not Present ❑Prresent,Removed Prior to Sealing ❑Other . If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE DRIFT- 1 19.5 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE l 1 M 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 I Type of Perforator - - toy I-.. ->a�';.; VARIANCE. 1/4/4'11r Was a variance granted from the MDH for this well?❑Yes [ No TN# . GROUTING MATERIAL(S) CEMENT 1 ttC w� Grouting Material NEAT CEMENT from 1 to 195 ft. yards 21 bags from to ft. yards bags \' from to ft. yards bags OTHER WELLS AND BORINGS I Other unsealed and unused well or boring on property? ❑Yes No How many? - LICENSED OR REGISTERED CONTRACTOR CERTIFICATION i 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 WELL DRILLING CO. ,INC. 1691 1 Licensee Business Name - License or Registration No. 558 25 rfreffa V€ r not a Certified Rep.No. Date r JERRY - A LOCAL COPY " 415 615 Name of Person Sealing Well or Boring , HE-01434-17 ID#53159 11/19R ' . _ _ _. .. .._ . . _ ...... -, . __. _ _,. . .._ _:... '- . .- ._