Laserfiche WebLink
MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ������ � <br /> WELLOR BORING LOCATION WELL AND BORING SEALING RECORD �aling No. �H_ <br /> Counry Name Minnesota Unique Well No. -- <br /> Mmnesota Statutes,Chapter)031 or W-series Na � � <br /> @�lY]ep 1� 0.seve mnx n oa k�ow�� <br /> Township Name Townsh�p No. Range No Section No. FracGon�sm.-s ig.) Date Sealed Date Well or Bonng Constructed <br /> rono 117 23 Ofi 2�1-�00� 2� v�},� <br /> Numerical Street Adtlress or Fire Number and Ciry of Well or Bonng Locahon . <br /> i�8� B�i/f3�{�Q �i()�j�� Q;'0�(� Depih Before Sealing ��� r it. Original Depih � �� ' h <br /> Show ezact Ixation of well or bormg C G Sketch map of well or boring ApU1FER�S) STATIC WATER LEVEL <br /> in section grid with"X'. 5 J 3 J 9 locat�on, showing property Single Aywter � Multiaquiter <br /> li es,road�s,an bwldings. <br /> - N � � . �,y ��.� WELUBORING .�Measured ❑ Estimated <br /> -- - - -- -- -- -- -- � '... �Water Supply We�l ❑Monit.Well � <br /> �� ❑ Em.Bore Hole ❑Other _ ��ft. �below ❑ above land surtace <br /> W --�- -i-- -i-- —i— E ��� CASiNG TYPE(S) <br /> � � � <br /> , D <br /> � � � � <br /> �. —�- -i-- -r- --�- � (�Steel ❑ Plastic ❑Tile ❑Other <br /> Ylmile T <br /> —�- -i-- -i-- --i-- I CASING(S) <br /> � �� Diame/1er' Depth � Set m oversize hole9 Annular space initially grouted? <br /> l S J� [�.! ,/�,y/C� <br /> �i mae—�1� � in.from O to I�1 tt. ❑ �es �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> UOPeERT�O�uE�R'SNAM�52_747—�GG� in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> tl V V <br /> Property owner's mailing address it ditterent than well localion address indicated above. in.from to tt. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> ♦��� r � <br /> Screen hom L�S.L ro��.ft. Open Hole irom to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME �Rods/Dro Pi /'') <br /> p pe ❑ Check Va�ve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owners mailing address if dilferent than properry owner's atltlress Indicated above. Type ot ObslruCtionS(DesCribe)�����/ti �/�� ¢ / Ur' ,� <br /> Obstruclions removed? Yes ❑ No Describe <br /> PUMP h <br /> Typg SVQ� ! �R9 �� <br /> 6EOLOOICAL MATERIAL COLOR MARDNESS OF FROM TO emoved ❑ Not Present ❑ Other <br /> FOHMATION <br /> If not known,indicete estimeted fortnatbn bg from nearby well or bonng. METHOO USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> � -� r� <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from �e ry. ❑ PeAorated ❑ fiertroved <br /> in.from to tt. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> `�'7 J i <br /> Grouting Material /�L A/ C�/�s.'�r6m �_ ro L�G51 tt. yards �bags <br /> irom to fl. yards bags <br /> trom to fl. yerds begs <br /> from to__ tt. yards , bags <br /> REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 0725. The infortnation conteined in Mis report is <br /> � true to the best ot my knowledge. <br /> _ DonbSt�dola 63e21 Drilifn� Co. , Inc. 27172 <br /> Confractor Business ame License or Registrafion I'io. <br /> i ~ � <br /> // � {� r�� ^.�+f <br /> uth ed R resentative Signeture Dete <br /> LaCAI CO�Y H �Q��Q Z Name ol Person Seeling Well a Boring <br /> 6d <br />