Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I ���1 �� <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnle ota Unique Well No. J' <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> . (Leeve Wenk H not bwvm) <br /> Tawnship Na e Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> (?[Oi]ri 1�7 2 1� ��. �. � � � � <br /> , r <br /> GPS ��� de9rees minutes seconds f <br /> LOCATION: <br /> Depth Before Sealing �J R. Original Depth�� fl. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Welt or Boring Location Single Aquifer ❑MuRiaquifer <br /> 1J13 � �i Rd� O�fl'I� �5391 WELUBORING Measured ❑Estimated <br /> Water Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or bonng <br /> in section grid wtth"X" Ixation,showing property ❑Env.Bore Hole ❑Other �_ft. �below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> t <br /> Steel ❑Plastic ❑Tile ❑Other <br /> 1� <br /> W -- - -i-- -i-- --i— E `(1, WELLHEADCOMPLETION <br /> r <br /> � � � � � ,��� <br /> � � � � �- Outside: ❑Well House Inside: ❑Basement Offset ' <br /> —�- -�-- -i-- --i— � `� <br /> 1�� y/�Pitless AdaptedUnit ❑Well Pd <br /> --�- -�-- -�-- -�-- � j� <br /> ❑Well Pit ❑Buried <br /> S <br /> �'—'"'�'—�' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diam �r� Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owner s mailing a ress i erent n well location address indicated above /1 <br /> in.from5.� t0���ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑ves ❑No ❑ves ❑No ❑Unknown <br /> in.f�ortl to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> �j�J/� � f <br /> Well owner's mailing address if ditterent than properry owner's address indicated above Screen from��t0�ft. Open Hole from t0 n. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describel�,G.�s�'��'��/.� @ �/�YY� <br /> � <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YES ❑ NO Describe <br /> FORMATION <br /> If not known,indicate esfimated forma6on log from nearby well or boring PUMP <br /> Cj ; .,�, TYPe <br /> Removed ❑ Not P esent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIA�(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> / <br /> . Grouting Materia7lA�/f�,�,T�/?%tl?from�to�ft. yards �� bags <br /> _ � <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> ^r <br /> Contractor Busipess �ame �/ - �r��- License or Registration No. <br /> y�,; f ... ..-. <br /> ./ r.. ' � �-C <br /> �"` J�� .,�t. <br /> t n R� ��sentativeSignatu�e Date <br /> LOCALCOPY H �25139 ���JL��v� `,,_/"o�.�'�"� �-n-f�7�---- <br /> Name o/Person Sealing Well or Boring <br />