Well info - Laserfiche WebLink

Home Browse Search

' WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �o s 2 a o County� me WELL AND BORING SEALING RECORD Minnlego a�Unique Well No. Minnesota Statutes, Cha ter 103/ or W-series No. �$2� �.Q '° �ea�,e o�a�k��o�x�ow�� Township Name Township No. Range No. Sec[ion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Oroc�o 127 23 10 1�E � 3 v Igvl� t , GPS Latitude degrees minutes seconds Depth Before Sealing ��0 tt. Originaf 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 V �/.R� � nl�pp �� SS�92 WELL/BORING ,Measured ❑Estimated Date Measured��Q! _ ■r� � AZ 6 � '�Water-Supply Well []MoniL Well � Show exact iocation of well or boring Sketch map of well or boring - Q, in section grid with"X." location.showing property . �Env.Bore Hole ��_j Other_.___.,.___ _�=[__ft. �elow �_J above land surface N lines,roads,and building; CASING TYPE(S) � � � � � � t �� Steel []Plastic �Tile ��]Other --�-----'------`-----'-- •, ` o ELLHEAD COMPLETION � W W ; : : � ET � , ' r r Pitless AdapteNUnit C At Grade Inside: ❑Basement Offset " _ _____ ___ __ __ _____ Outside: ❑Well House ❑ , , , , Miie �Buried ❑Well Pit , � . , � , 1 ��' --;-----�--- --�-----%-- „ �') Buried l ' ]Well Pit � S ❑Other �i Mae-� �� ]Other PROPr�ERTY WNERS tNA�ME/COMPANY NAME CASING(S) i{J[ii . �lia � Diametp�� Q � Depth � Set in oversize hole? Annular space initially grouted? Property ownefs mailing address if diMereM than well location address indicated above � in.from to ft. ,_�,Yes o Yes _�� J ❑ ❑No ❑Unknown in.from ro ft. ❑Yes �No ❑Yes ❑No ❑Unknown � ______in.from to ft. ❑Yes []No ❑Yes ❑No U Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE '�� Well ownei's maifing address if differem than property owner's address indicated above SCfeen ffom �v� /_to__/,��•ft. Open Hole ffom to ft. OBSTRUCTIONS :; �Rods/Drop Pipe j�Check Valve(s) ��_'i Debris ❑Fill U No Obstruction Type of Obshuctions(Describe) �,fJf _f'L�7 4 �V�l� GEOLOGICAL MATERIAL COLOR HARDNESS oR FROM TO Obstructions removed? [�'es I No Describe FORMATION -- PUMP If not known,indicate estimated formation log from nearby well or boring. /� /� .f Type SU1� �UM p �". L' r' emoved �]Not Present ❑Other ' f METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�lo Annular Space Exists J Annular Space Grouted wiih 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 Ibs.,one bag of bentonite=50 Ibs.) � f Grouting Material �V�AT G�I�N7�m V to��ft _ yards__�� bags from to_ ft. yards bags i 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? [ .Yes �._�o 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. Don �todola tie21 Drilling Co,. Inc, 1691 Licensee Business Name License or Registration No. /� - y t .� Cert' d re e t tiv Signa r Certified Rep.No. Date 306240 ' ':�..,�. ��+ .�-- LOCAL COPY H � �"'� Name of Person Sealing Well or Boring HE-01434-12 IC#140-0423 �' g,�osrt