Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ���A n� <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. •7" <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank�A no�known) <br /> Township N Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> l l l. �/'1 i./ t t t� <br /> `y / <br /> GPS Latitude degrees minutes seconds Depth Before Sealing �'t�"• �� ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes__ seconds <br /> A�UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Muttiaquifer A, 1./ <br /> WEWBORING �J Measured ❑Estimated Date Measured..^�%J�'�" f.!/'�`' <br /> �Water-Supply Well [j Monit.Well <br /> Show exact location of well or boring � Sketch map of well or boring (f�' <br /> in section grid with"X" location,showing property ❑Env.Bore Hole U Other f .�-�. tt. �elow C�above land surface <br /> N i� lines,roads,and buildings. CASING TYPE(S) <br /> I � I I i <br /> . __'___ __'______`__ ___'__ - <br /> i Steel ❑Plastic ❑Tile ❑Other <br /> i <br /> ----- --------- ----- -- WELLHEAD COMPLETION <br /> � � � <br /> . <br /> � W ; ; : � ET <br /> ',. � � � � �`��r� � Outside: [J Well House f�At Grade Inside: ❑Basement Offset <br /> —�--- --�----�----.— <br /> ��M e"'� � ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> . , , , l �� <br /> --:--- --r----.-----:-- <br />^-��� ' S ' g �` [_]Well Pit ❑Buried <br /> ` �Other <br /> �1 Mile� �*' ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth ► Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address it different than well location address indicated above �� /) <br /> - �in.from U to �v R ❑Yes �No ❑Yes ❑No ❑Unknown <br /> ��O �T����U$ ��TJ "" t in.from ro ft. ❑Yes n No ❑Yes ❑No ❑Unknown <br /> ID� L3llC+ L717 S53�V <br /> in.from to _ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE ' , <br /> Well owner's mailing address if diNerent than properry owner's address indicated above SCfeen from�_to_��ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> � Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> ',� ' TYPe <br /> '��-i" ���� / ,� ❑Removed ��1Mot PreseM ❑Other ___.___ _, <br /> ,7\ <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [�Qo Annular Space Exists []Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal �; <br /> Jt <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> s <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> r <br /> Grouting Material�/'����C_����✓from� to� ft. yards_�_ bags <br /> from to tt. 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 o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> Don Stoclula Well Drillfng Cv,, Inc. 1691 <br /> Licensee Business Name //'� License or Registration No. <br /> ,,p �G�'��C��S{��- ...-�('. /� � �� 5 <br /> -+"'"��� ..'%" ..�.'� -r� �r <br /> C ie e resentative Signature ' . Certified Rep.No. Date <br /> i ��S <br /> ' I..00HL COPY H 2���O� _ � �. ..�"-.. _.,��-''F-1-.^r'r"-- ,. <br /> Name of Person Sealing Well or Boring � <br /> HE-01434-10 IC#140-0423 ' sio�a <br />