well info - Laserfiche WebLink

Home Browse Search

WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' _ '+ °� g� � County Name WELL AND BORING SEALING RECORD Menn'ego a�Unique Well No. O Minnesota Statutes, Chapter 1031 or W-series No. t* (Leave blank it n01 known� � Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed � � �I�',� �. S OCT - 1 GPS LOCATION- decimal degrees(to four decimal places) Depth Before Sealing_ �O� • _fL Original Depth _ _ft. Latitude____ ______ Longitude IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Borin LCocatLion� . .Single Aquifer �, ;Multiaquifer �/ /1�/ 42i 5 Farest Lake nC� �rQ� �1�C7�f WELUBORING ,/?Measured ',_ Estimated Date Measured��f �f"�r _ Water-Supply Well i ,�Monit.Well ,�j r Show exact location of well or boring Sketch map of well or boring r-,Env.Bore Ho�e ]Other �r ft. below in section grid with"X:' lo ation,showi property __ _— �' �._�above land surface N .� li s,ro ds, r�p.suiqdiM1�S�_ ,�ASINGTYPE(S) t�.n � � � � .. --'-- -'-- � � , ---"- -_'_ i� 1 � �Steel . ,Piastic . .Tile _J Other ___ __ __ __ --'--- -�'--' '--�-----�-- WELLHEAD COMPLETION � W � � � � E �� � � � � T `- Outside: �.]Well House � 1 At Grade Inside: ❑Basement Offset --;--- -�--- --�-- --%-- I . . � � � � '/Mde � A � I � uried �I Well Pit --;--- --;--- ---'-- ---;-- � � �Wtess p r/ nrt �Buried i da te B � ell Pit S , ❑Other - -- -�-- ----- �—�Mile—� I J�ther _ _ PROPERTY OWNER'S NAMEiCOMPANY NAME CASING(S) r Diameter � Depth � Set in oversize hole? Annular space initially grouted? Propeny ownefs mailing address if different Ihan well location address indicated above � - � In.from_� to�� ft �;Yes `�o _._Yes ��,,i No ❑Unknown in,from__ _ to__ _ft. ❑Yes '� �No �_Yes ','�'��No r...,Unknown __ In.from to ft []Yes � I No ❑Yes I�No ��Unknown � WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � - / Well owner's mailing address�d dlfferent ihan properry owner's address indlc�ted above SCreen from �_to��y��it. Open Hole from t0 ft. OBSTRUCTIONS i�Rods/Drop Pipe I Check Valve(s) f �.Debris , ..Fill �, ;No Obstruction )� �-(L_.� �_�� .. Type of Obstructions(Describe /Vl� 1/''r T GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �� Yes I.j No Describe �� FORMATION ""----�--"---- � --- ' PUMP If not known,indicate estimated formation log from nearby well or boring. ' ` J� TYPe-__ __--- -- C....� '�. 1 Removed �� ,�jVot Present [,Other . METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo Annular Space Exists �. �Annular Space Grouted with Tremie Pipe '..,Casing Perloration/Removal in.from to_ ft �_)Perforated []Removed . _____________in.trom. _. . .__. to__ .___ ______ft. [_]Perforated �_I Removed ` Type of Perforator VARIANCE Was a variance granted from the MDH for ihis well? '_ Yes �No TN#___ _ . __ _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) / /' � Grouting Material�f�/ �i�_f��(/ hom � to 1�,�!� ft.___ . ._ yards__�__ bags from to . ft. yards___ bags ( ____ from_ to___ ft. yards_ bags OTHER WELIS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? � i Yes ' o How many?____ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordaoce with Minnesota Rules.Chapter 4725.The information contained in this report is true to the best of my knowledge. 1I� Stodola s,rell ?3ril�i�; Co., Inc. 1691 Licensee Business Name - . License or Registration No. £,'"' .__� � r' " c�'-� � - t� - -- "' �- ---- — _ _ htative Signatur�,.:� � Certilied Rep.No. Date " 3 3 3118 � r-�"-�`"�.r`, LOCAL COPY -- _. _ — -- _-- - -------- . ___ - ----- - — - Name ol Person Sealing Well or Boring HE-01434-14 IC#140-0423 � 5;iaa