01-31-23 Well & Boring Sealing Record

Home Browse Search

MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H WELL oR BORING LocarloN WELL AND BORING SEALING RECORD Sealing No. �14 CountyName Minnesota Unique Well No. AENNEPIN q Minnesota Statutes,chapter 1031 ONO or W series No. ,f (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.—lg.) Date Sealed Date Well or Boring Constructed • 1,,t •j LA&E 116 23 33 SOSENL '/^ 1/31/23 GPS LOCATION— decimal degrees(to four decimal places) Depth at Time of Sealing .U 1 ft. Original Depth ft. Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address r Fire.Number and City of Well or Boring Location IX Single Aquifer El Multiaquifer if�(� ®Measured Date Measured £ L f j ❑Estimated 3 ct KA ....e St' i 1�/ WELLBORING Water Supply Well ❑Env.Well Show exact`o6Micin of-weft-crh 6" - -- p vf.well_oC.,la ri3O" 50 in section grid with"X." owing property ❑Temp.Boring ❑Other ft. below ❑above land surface N _<, ,. <; ," ,and build gs. CASING TYPE(S) 1 ❑Steel X Plastic ❑Tile ❑Other lj fr r- --------------•---`------f--- WELLHEAD COMPLETION W ET r 1 r" Outside: III Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset it' - ' Mile 4:.+ ❑Well Pit ❑Buried ❑Well House ---; T ,- i"" ❑Well Pit s ❑Other ❑Buried 1 Mile f ❑Other For temporary borings,provide additional location CASING(S) information,a site sketch,and geology on a separate page. I Diameter Depth Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from I to 15 7 ft. ❑Yes ❑No ❑Yes ❑No zo Unknown BOB ERICKSON Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 2435 lltAYZATA L LVD I in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown LONG LA i ,r AN. 55356SCREEN/OPEN HOLE 157 r Screen from to ft. Open Hole from to ft. WELL OWNER'S NAME/COMPANY NAME OTC° PROPERTIES INC OBSTRUCTIONS Well owner's mailing address if differentr► than property owner's address indicated above ®Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction 2435 WAYZA#A BLVD R Type of Obstructions(Describe)DROP PIP LONG LAKE, AA. 55356 Obstructions removed? x Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO FORMATION ❑Not Present I Present,Removed Prior to Sealing ❑Other If not known,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE DRIFT 1 161 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 F]No TN# GROUTING MATERIAL(S) NEAT CEMENT T 1 161 16 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 Fl No How many? i LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 1 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 . iis true to the best of my knowledge. il�O SIOD LA t L1 tam . , x 10 1 ( Licensee Business,Nameev License or Registration No. --,e;?.?" ,, ,::"":,: --e-c----/.,1:. ' :::,;;.,..4-- -:— 1/31/23 ertrtied representative Signature Certified Rep.No. Date c JMUX B A R H CI '1 /I i LOCAL COPY Name of Person Sealing Well or Boring HE-01434-17 ID#53159 t i/19R