3255 Sibley Memorial Hwy - Well & Boring Sealing Record 2021-12-29'25 6ibic' WAIL
Show exact location of w I or boring
in section grid with "X."
w
s
1 Mile
'h Mile
WELL OR BORING LOCATION
County Name
DC0'4) CI—CL/
Township Name
tt
MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes, chapter 1031
Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
(Leave blank if not known,
Township No.
Range No.
1?:'
Section No.
Fraction (sm. —, Ig.)
5 Li4
Date Sealed
1
u
GPS<1r_CATION — decimal degrees (to four decimal places)
Latitude Lcngitude
Depth at Time of Sealing 31 5
_
ft.
Numerical Street Address or Fire Number and City of WeII or Boring Location
4
56121
Sk- ch r of well or boring
location, showing property
Tines, roads, and build pgs.
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.
AQUIFER(S)
j, Single Aquifer ❑ Multiaquifer
WELUBORING
j Water -Supply Well ❑ Env. Well
❑ Temp. Boring ❑ Other
PROPERTY OWNERS NAM _/COMPANY NAM
Crni (Lc n
Propefty owner's mailing address if different th well location address indicated above
25) Av-Ls-5-
41 y n . , 71 t '--I
WELL OWNER'S NA E/COMP NY NA E
ell oviner's mailing address if different than property owner's address indicated above
kA-CtJ)3 .t\V"
1011-eapo 161
CASING TYPE(S)
Date Well or Boring Construct
I\JA-
Original
Depth ti Aft.
STATIC WATER LEVEL
Measured Date Measured 53!/*24
❑ Estimated
72.
ft.
elow above land surface
teel ❑ Plastic ' Tile ❑ Other
WELLHEAD COMPLETION
Outside: ❑ Pitless Adapter/Unit
❑ Well Pit
❑ Other
❑ At Grade
❑ Buried
Inside: ❑ Basement Offset
❑ Well House
I Well Pit
uried
❑ Other
CASING(S)
Dia, eter Depth Set in oversize hole? Annular space initially grouted?
in. from to C ft. ❑ Yes '`'gNo ❑ Yes ❑ No Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
Screen from
to ft. Open Hole from to =1 ft.
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
If not known, indicate estimated formation log from nearby well or boring.
NA -
OBSTRUCTIONS
,Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
� -.
Type of Obstructions (Describe) t ZO t CLA '(' Pia_typ
Obstructions removed? XYes ❑1 No Describe
PUMP
❑ Not Present [Present, Removed,Prior to Sealing ❑ Other
Type6u_brney-3I
:
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
asing Diameter
in. from to ft. ❑ Perforated ❑ Removed
in. from to ft. ❑ Perforated ❑ Removed
Type of Perforator
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes )Jo TN#
GROUTING MATERIAL(S)
Grouting Material t\ICs-'from , to d✓ ft. yards 2.1-+
bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? P1 Yes XrNo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
trc, by--) p()_ci iS(‘,0
Licensee Business Name License or Registration No.
214 Vi—II22
Certified Representative Signature
k-Ao. ht
Certified Rep. No. Date
Name of Person Sealing Well or Boring
11/19R
HE-01434-17 ID# 53159