Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 4 0 8 8 0 3 <br /> R BORING LOCATION SWELL AND BORING SEALING RECORD Minnesota lNo.Unique Well No. <br /> HENNEPI N Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leaoe dank,t not known) <br /> Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> 1N0 117 23 07 $W'1 SW SM 3/20/2024 <br /> ATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 116 ft. Original Depth ft. <br /> e Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Street Address or Fire Number and City of Well fopr Boring <br /> gtLoocation [Single Aquifer LI Multiaquifer <br /> (It <br />(Q REST POINT RD.;t-i©4AL�f WELL/BORING Measured Date Measured 3/20/24 ❑Estimated <br /> j]Water-Supply Well ❑Env.Well 46 <br /> 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 <br /> N lines,road : .buildings. CASING TYPE(S) <br /> ' \ <br /> [ISteel ❑Plastic ❑Tile ❑Other <br />--' ---`------'--- <br /> °} WELLHEAD COMPLETION <br /> E ' <br /> T Outside: [ Pitless Adapter/Unit LI At Grade Inside: LI Basement Offset <br /> 'h Mile ❑Well Pit ID Buried LI Well House <br /> 1 )l ❑Other ❑Well Pit <br /> S ❑Buried <br /> t Mile---I <br /> ❑Other <br /> nary borings,provide additional location CASING(S) <br /> in,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> EYOWNER'S NAME/COMPANY NAME 4 in.from 1 to 108 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown <br />'RO HOMES <br /> vner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ['Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLEp <br /> INER'S NAME/COMPANY NAME DOBLIN y� Screen from 108 to 116 ft. Open Hole from _ to ft. <br />:ENE & GALINA DOBLIN OBSTRUCTIONS <br />'s mailing address if different than property owner's address indicated above L3 Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill LI No Obstruction - <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? [I'es LI No Describe <br /> PUMP <br /> IGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present gi Present,Removed Prior to Sealing El Other <br /> wn,indicate estimated formation log from nearby well or boring. Type SUBMERSIBLE <br /> FT 1 116 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> A No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe LI Casing Perforation/Removal <br /> Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes 7IU No TN# <br /> GROUTING MATERIAL(S) �+ <br /> Grouting Material NEAT CEMENT from 1 to1.16 ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes C No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> 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 <br /> is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. ,IHC, 1691 <br /> Licensee Business N me License or Registration No. <br /> 558 3/20/24 <br /> ert.d epressentativeSignature Certified Rep.No. Date <br /> LOCAL COPY El4 0 88 0 JERRY BARB <br /> Name of Person Sealing Well or Boring <br />-17 ID#53159 11/19R <br />