Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring !1 <br /> WELL OR BORING LOCATION H ������� <br /> �o��,y;a;e WELL AND BORING SEALING RECORD Minnleso a�Unique Well No. <br /> �j Minnesota Statutes, Chapter f031 or W-series No. <br /> �[j�j��E��� (Leave blank il not knownJ <br /> Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed <br /> RONO 11? 23 OT F! NW I'E �j <br /> (� � <br /> GPS Latitude __ degrees___ minutes___ seconds Depth Before Sealing �v ft. Original Depth ft. <br /> LOCATION: Longitude _ degrees__ minutes____„ seconds <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer /�/'y� n��y <br /> W LUBORING ,Measured ❑Estimated Date Measure�i f!•�� � l <br /> t <br /> � � �Water-Supply Well ❑Monit Well �,,. <br /> Show exact location of well or boring C G�S ketch map of well or boring —. <br /> in section grid with"X." J 3 V`iocation,showing Pr�perty ._;Env.Bore Hole ❑Other �ft.x]below ❑above land surface <br /> ines,roads,and�i+ddings. <br /> N �� �,_�� CASING TYPE(S) <br /> ,pr.,,. �,�'y_e..>�.�.i <br /> .' __'___ __'___ ___`_____'__ <br /> Steel [�Piasno ❑rie ❑Other <br /> � --;--- ; ; ; <br /> --�----'`-'---`'- WELLHEAD COMPLETION " <br /> W ; ; ; ; ET � <br /> __�___ _;.___�_____r__ � `� Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset ? <br /> 'fz Mile „� b/ �Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> ' --�-----�------%-----�-- "� <br /> ♦7' ❑Buried <br /> S . ❑Well Pit <br /> �-1 Mile <br /> � ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diammmjjj t��{ � Depth t Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing if ocation address indicated above C�/ �,/ <br /> �in.from_���_ to��ft. ❑Yes JtiL No ❑Yes ❑No ❑Unknown <br /> —1 <br /> $$j�Q in.from _ to ft. ❑Yes ❑No ❑Yes (]No ❑Unknown <br /> 952-472-0854 <br /> in.from to ft. ❑Yes ❑No ❑Yes []No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> � t <br /> Well owner's mailing address if different than property owner's address indicated above SCreen�rom�_to�R. Open Hole ffom, 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 /> � ��Removed �y Not Present ❑Other <br /> / \ <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 MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) w��. <br /> �y ...�� � �'7,.� . <br /> { <br /> Grouting Materi�����%/�,L.'/from� to� ft. yards_�_ bags <br /> � <br /> from to ft. yards bags 6 <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 /> j, 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 ta the best of my knowledge. <br /> DON STODOLA NELL DRILLING CO., INC. 1691 <br /> Licensee Busi es �ame License or Registration No. <br /> / y ✓'.�.ir �l � f' �� / �!' !L� <br /> rtified Representative Signature Certified Rep.No. Date � <br /> , LOCAL COPY H 2 Q 5 7 O i. � �'`_` <br /> i `J Name o/Person Sealing Well or Boring <br /> HE-01434-11 IC#140-0423 . 2/oea <br /> '�� <br />