Laserfiche WebLink
i, , _ _ :. _ � <br /> � ' <br /> MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��'7��(� � <br /> WELL OR BORING LOCATION SBflllfl9 NO. II H ( �) <br /> Counry Name — WELL AND BORING SEALING RECORD Minnesota Unique Well No. r <br /> y{�y Mmnesota Staiutes,Chapter 1031 or W-series No. I I <br /> ��il Li� �� .. 0.�ew tleNc M iwl known) L_ _f <br /> � Township Name Township No. Range No Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Bonng Consiructetl <br /> ttro�o I I7 23 3 7 4��fl9 G> <br /> Numencal Slreel Adtlress o�Flre Number and Ciry o�Well or Bonng Location � � <br /> 34�9 Lyric ��� ' ����0 5�391 Depth Before Seahng�_R Original Depth h <br /> Show ezact locahon ot N•ell oi boring Sketch map of wetl or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid wrth"X". , locauon, showing property Single Aqwfer ❑ Multiaqwfer <br /> lines,roads,and buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well r <br /> ❑ Env.Bore Hole ❑Other _ _ � tt. � below ❑ above land suriace <br /> W —�- - -- - -- --i— E CASING TYPE(S) <br /> � � � <br /> , � <br /> � � � � <br /> ''r- � <br /> -;-- --,— --�-- Steel � Plasfic �Tile � Other <br /> }lmile <br /> ' —�- -�-- -�-- --i-- � CASING�Sj <br /> Diameter Depth j Set in overs�ze hoie7 Annular space initially grouted7 <br /> s �! 1� � <br /> �—i mna� in from � to n ❑ ves No ❑ ves �No ❑ unknown <br /> PROPERTY OWNER'S NAME in.from � to ft ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> Pro wn s i � i erem th a� �res � bove. in.6om to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> ���C ������ �SL� Q� SCREEWOPENHOLE f <br /> 3 A R /,/,rw�r��/'�� <br /> ryr���� � ���}�y� Screen from C�to��tt. Open Hole from to ft. <br /> V J7 <br /> OBSTRUCTIONS <br /> � WELL OWNER'S NAME �Rods/Diop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> �/�/,��/� /�e y.� /� <br /> Well owner's mailing address if diHerent Man propeAy owner's address indicated above. Type ot ObstruCtions(Describe) .j/� r"�.�/[- /'�: !�"� ��///J�"� <br /> Obstructions removed? Yes ❑ No Describe <br /> ..,,�. PUMP /'� <br /> TYpe ..�C.}C3 {�� <br /> GEOLO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> � FORMATION <br /> fl not known,intlicate estimated�orma�bn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: � <br /> �r��� �lo Annular Space Exists <br /> � � ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> � in.from to R. ❑ PeAoreted ❑ Removed <br /> in.trom �o n, ❑ PeAorated ❑ Removed <br /> Type of peAorator <br /> ❑ Omei <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> tr <br /> Grouting Material � ` f �m � to Sl� R. yards _� bags <br />�� <br /> @ <br /> i� from to ft. yards bags <br /> � trom to n. yards begs <br />' - from to__ R. yards begs <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHEFi WELLS AND BORINGS <br /> '� Other unsealed and unused well or boring on property? ❑Yes o How many? <br /> :i i, LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Hules,Chapter 1725. The information contained in this report is <br /> � true to the best of my knowledge. <br /> C�g$Bd.�A���'�—���r�j�V�"�orReg�__�� <br /> ,.a :^ <br /> '.e�'.r ./'/ !.,-a'�� i� ��"''£1""VU <br /> onz Representative S�gneturs' Dafe <br /> 3f� �ntonson <br /> �p(���'��„"� � ���w A Name ol Person Sealing Wel1 oi Bonng .. <br /> . . H fc�, <br />