well info - Laserfiche WebLink

Home Browse Search

MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �C�Q O /t WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. H `� "� �� County N e � Minnesota Statutes, Chapter 103L or W-series No. in ,�ea�a b�a�k�,�o,k„aw�, Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed corio I18 23 32 '' '' '' Latitude degrees minutes seconds De th Before Sealin � ' '� GPS P g—/ / ft. Originai Depth ft. LOCATION: Longitude degrees minutes ._ seconds �UIFER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �._,'�Multiaquifer - ."',� WELUBORING Measured ❑Estimated Date Measured � �� Water-Supply Well �]Monit Well r Show exact location ot wel boring map o well or oring �� in section grid with"X" loca on,showing prop rty �J Env.Bore Hole � 'Other I_S�ft.�below ❑above land surface N line r and buildi gs� �ASINGTYPE(S) � --'-----'-----`----'— ��`.=� '�,� Steel ❑Plastic ❑Tile ❑Other ��: --'--- --�------`----'-- WELLHEAD COMPLETION � : W _ �_ _; __ � _ _r E T •� utside __ ell House ,_ t Grade Inside. asement Offset I O : [�W ir�A ❑B :' , , , , Miie dless A p dUnd ��guried ❑Well Pit - 'h ;, , . , , � � �P' da te ' , •. --�--- --�----�----�- - ❑Buried ' S ' ❑Well Pit ❑Other r 1 Mile� �� U Other i p�•nPERTY O�NNFr,,•nin••—,• - •,• .,•..••_ CASING(S) Y'��.,,'��,'�e - � � _ � Dia �� Depth � Set in oversize hole? Annular space initially grouted? Y'. �q /� j Pro�e�[y dwnei.,�A2i �� ss if different than well location address indicated above �in.from (/ to /2/_ft ❑Yes �o ❑Yes �]No U Unknown i ' in.from to ft. �_]Yes ❑No ��]Yes ❑No ❑Unknown in.from__ ro ft. U Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t � Well owner's mailing address if different than properry owrzr's address indicated above SCreen from��,_to��• ft. Open Hole from to ft. OBSTRUCTIONS _,Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction Type of Obstructions(Describe) _.________ _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑fvo Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � Type �—ti-' � �_1 Removed �Not Present ❑Other_ ____ ___ s � � � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: - No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from ____to_ ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94�bs.,one bag of bjntonite=50 Ibs.) Grouting MaterialN!G/�f��//�/�// from � to� ft._ _ yards�___ bags ___ from _ to ft. yards _ bags from to _ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? r'��Yes �� No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The iniormation contained in this report is true to the best of my knowledge. ��toclola t�Z1�ri11in�Co.� In�.--�.b�l -- Contractor Bus ss ame License or Registration No. ��..�__ J- /:>=� r:�:�? -:��:r � Certified Representative Signature Certified Re�o. Date : ' \` j � �,�. , K Y"�,—?r„�,, i LOCAL COPY � 2 5 4 9 0� Name of Person Sealing Well or Boring HE-01434-09 IC#140-0423 � 6/osa