Laserfiche WebLink
.;{_.a ,.,: <br /> �- . � �" � <br /> � � �� � <br /> / MtNNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +� ��f'��� <br /> WELL OR BOFING LOCATION �yELL AND BORING SEALING RECORD Seaiing No. H 1 L _ � <br /> co�nry Name Minnesota Unique Well No. <br /> � Minneso�a Statutes.Chapter 1031 or W-series No. <br /> Hsnne in n..,.d,���.�� -- -- -- � <br /> Township Name Township No. Range No Section No. Fracuon Ism �Ig) Date Sealed Date Well or Bormg Consiructetl <br /> Orcuio 117 23 2A 'SE �FT `� � 01/25/02 � � <br /> Numencal Sireet Adtlress or Fire Number and Ciry of Well o�Bonng Locahon � � <br /> �7� SY�Or2�.1T� DriV� Depth Before Sealing 1� n Original Depih h <br /> w ex loca i of H• Sketch map of well o�boring ApU1FER(S� STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Q Single A�wfer ❑ Multiaquiler �� <br /> lines,roads.and bwldings. <br /> N WELUBORING �Measuretl ❑ Eshmated <br /> , � � � <br /> �Water Supply Well ❑Monit.Well <br /> -'r- -i-- --i-- --� <br /> , �e i, ❑ Env.Bore Hole ❑O�her _ � tt. �below ❑ above land surface <br /> :-s. <br /> W -- - -- -i-- --i-- E ^�- CASING TYPE(S) <br /> � � <br /> � OASP MPq� <br /> � <br /> —i-- -i-- -i-- --�-- � U �Steel � Plastic �Tile �Other <br /> Yimile <br /> —`- -j-- -�-- --�-- � CASING(S) <br /> Dlameter Depth Set in oversize hole9 Annular space initially grouted7 <br /> L� S "�� ^ 1s <br /> �I(�—t mi�e� ` in.from 0 b 1V3 ft. ❑ Yes p No ❑ �es ❑No � Unknown <br /> I <br /> PROPERTV OWNER'S NAME in.from to it. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Property owner's mailing address il diHereM t�an well loca6on address indicated above. in.�rom to ft. ❑ Yes ❑No ❑ �05 ❑NO ❑ UnknOwn <br /> � � � SCREEWOPEN MOLE <br /> Crystal Bay I� 55323 ' S�,ee�,,om 163 ,o I68 n <br /> . . Open Hole irom to fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �� Rods/Dro Pi e O ❑ Debris ❑ Fill ❑ No Obstruction <br /> � p p ❑ Check Valve s <br /> Well owner mailing address if diNerent than properry owner's atltlress indicated above. Type ot ObStruCtionS(Describe) <br /> Obstructions removed? .Yes ❑ No Describe <br /> PUMP <br /> .. TYPQ S�SO� <br /> HARONESS OF � Removed ❑ Not P�esent ❑ Other <br /> GEOLOOICAL MATERIAL COLOR FORMATION FROM TO <br /> If rat krawn,irWicate eatimeted formeuon log from nearDy weli or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.irom to R. ❑ Pertorated ❑ Rertroved <br /> in.from to h. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ otner <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Matenal ��i� from � ro 26$ ft. yards � bags <br /> , .. from to ft. yards bags <br /> from to ft. yards begs <br /> from to__ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG OTHER WELLS AND BORINGS <br /> ���� /� Other unsealed and unused weli or boring on property? ❑Yes �No How many? <br /> PD- j�� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> T.L. Stevens Well Co�ar�y 27194 <br /> Contracror Business Name License or Regisfreb'on l�io. <br /> Authonzed Representative Signature Da e <br /> �ff iTa�-nn <br /> 1 FOFR7AN o �L�''�'d � �i�Jr�.�-:! + <br /> H ��/1/�/�� Name ol Person Sealing Well a Bonng <br /> f� PERS-Vlr� �'vti;�iEF a„'' ' V L V <br />