Laserfiche WebLink
wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' n I�� <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. L L <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leeve dank il nd knonn) <br /> Township Na e Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> flrono 127 23 t� �,. �,. .,. O c.. <br /> GPS Latitude degrees minutes seconds ` � � <br /> LOCATION: Depth Before Sealing ` �� ft. Original Depth��� ft. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 31�� cL�a, !�s vi� 5535b ELUBORING �lvleasured ❑Estimated <br /> Ea.... <br /> r� <br /> Water Supply Well ❑MoniL Well � t l <br /> Show exact location of well or boring Sketch map of well or boring C, <br /> in section grid with"X" location,sho ing property ❑Env.Bore Hole ❑Other 7 ft. �below ❑above land surface <br /> lines,roads,tand buildings. <br /> N � _ CASING TYPE(S) <br /> �. z.� <br /> __...�'--'_'""_� _ -. <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> W -- - -�-- -;-- --,-- E WELLHEAD COMPLEl10N <br /> r � Outside: ❑Well House Inside: p(Basement Offset <br /> -�- ---- -i-- -i-- �� j� <br /> ��y ! <br /> ❑Pitless Adapter/Unit ❑Well Pit <br /> --�- -�- -�-- -i-- I <br /> Z ❑Well Pit ❑Buried <br /> �,�..—�. �-'�_��: <br /> ❑a��� <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diamet�r Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diNerent than well location address indicated above �(�,',�/ <br /> �_ in.frOm� t0_,C�.aL ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 515 lst Av+� N in,f�Ort1 t0 ft. ❑Yes ❑Na ❑Yes ❑No ❑Unknown <br /> Isanti, �T S5t14f) <br /> in.f�Ofn t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> > <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> � � <br /> r <br /> Well owner's mailing address if diHerent Man property owner's address indicated above Screen from t0��ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> `Q�Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> /'� /� <br /> Type of Obstructions(Describe) � .t//,� �r/.�6 � �""(J/)')!� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? Yes ❑ No Describe <br /> FORMATION <br /> If not known,indirate estimated formation log from nearby well or boring <br /> PUMP <br /> - � � � TYPe ,� � <br /> Removed ❑ Not Pr sent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> � Lyf No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> /' <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> f <br /> Grouting Material�f�r��,'��'�,�+�from�—ro��jt. yards � bags <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 information contained in this report is <br /> true to the best of my knowledge. <br /> dcx� Stodflla Well llrillin� Co,. �, znr� <br /> Contractor Business Name License or Registration No. <br /> r---- � /; � <br /> .�.. �-� . ,� f ;� f <br /> A o ed epresentative Sig�77atm�e Date <br /> -A.�� <br /> H '2�?61 �. ; .:,_,.,�. <br /> LOCALCOPY � <br /> Name of Person Sealing Well or Bonng � <br />