Laserfiche WebLink
WELL OR BORING LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ��1 o f1 A � � <br /> --- WELL AND BORING SEALING RECORD Sealing No. H A1 i�.l <br /> Co�r,ry Name Minnesota Unique Well No. --- <br /> �j �{}�p Mmnesota Statutes,Chapter 1031 or W-series No. � <br /> £a.�f 3 LF G �� (�eeve MeMc 1/�wt krrown) <br /> Township Name Township No. Range No Section Na Fraction Ism.-►Ig� Date Sealed Date Well or Borirg ConsVuctetl <br /> Orana 11 2� �t� 'i�=t303 �=? , -, <br /> Numencal Street Atltlress or Fve Number and Ciry of Well or Bonnq Locafion � / ,. <br /> �'f 3� � is�k.� �4 V r��� S 5 356 Depth Before Sealing��'� ft Onginal Depih �/ �' ._n <br /> Show exact location of N•ell or boring Sketch map ol well or boring AOUIFER(S) STATIC WATER LEVEL <br /> m sec6on gnd wrth"X". location, showing property � ingle Aywfer � MulLaqwfer <br /> _ lines,roads,and buildings. <br /> N , i .� � ELUBORING Measured ❑ Eshmated <br /> 0 <br /> � � � � ----^� � ' -�� �"���� �Water Supply Well ❑Monif.Well � <br /> � � � <br /> ---�---_. --^-. <br /> _'r_ _�__ _�" _'�_- . <br /> # ❑ Env Bore Hole ❑Other _ _ tt. �below ❑ above land surtace <br /> I 1 I I _...----- <br /> W -- - -�-- - -- --�-- E ' � j CASING TYPE(S) <br /> : r , <br /> � , - <br /> � � <br /> � � � � <br /> -�— ' < . <br /> ---- - -- —�-- � � r �Steel � Plastic �Tlle �Other_ <br /> � � � � tt � <br /> -�-- -i— -i-- --�— �ilef� � � ` CASING(S) <br /> :'�(+ Diameter Depih t Set in oversize hole7 Annular space initially grouted? <br /> �rmrie—a►e �.�s_�-�-.-3 _ ��eT�m.Irom�� to�� R. ❑ Yes ICI110 ❑ �es ❑ No ❑ Unknown <br /> i `7S <br /> PROPERTV OWNER'S NAME in.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> �i'A 9I�f8t H �£�� <br /> Propeny owner's malGng address If diHerent than well location address indicatetl above. in.irom to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown <br /> 2964Q Silver Lake l�l SCREEWOPENHOLE <br /> r � <br /> �hOC@WOOt�� �SN SS��1 � <br /> Screen from_..��ro� ft. Open Hole irom lo fl. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �qNo Obstruction <br /> / ' <br /> Well owners mei6ng address if ditterent than property owner's atltlress mdicated above. Type of Obsiructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOL061CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed �Not Prese�t ❑ Other <br /> FORMATION <br /> If not known,indicate estimated lormatan log from nearby well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: <br /> 3 �lo Annular Space 6cists <br /> �'---�`' �� � �'�-' �O Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to ft. ❑ Pertorated ❑ fiemoved <br /> in.from ro ri. ❑ FeAoreted ❑ Removed <br /> Type of perforator <br /> ❑ other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> , �,>,. <br /> Grouting Material��fv f �%�f����r�m �_ to�� ft. yards _� bags <br /> from to R. yards bags <br /> from to n. yaros bags <br /> from to_— ft. yards bags <br /> REMARKS,SOUIiCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonng was sealed in accordance with Minnesota Rules,Chap[er 4725. The informatio�co�tained in Mis report is <br /> true to the best of my knowledge. <br /> �vn �tt�dola t�ell Driliin� CQ. , Inc. 27172 <br /> Contracfor Business Name License a Regisfretion I'ro. <br /> --�r7 /'.'"_= - �� . <br /> � /d'�%. ,_ � _..�v. -� ., �':... <br /> � ,.y z e sentative Signaltlre Dete <br /> --y„ <br /> � _ '._. . ..J;..,r...,`�. <br /> 2����� Name o!Person Sealing Wel1 or Bonng <br /> LOCALCOPY H <br />