Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 4 2 21 <br /> County Name <br /> WELL AND BORING SEALING RECORD Menn�e90 a�Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> f����/� �^ (Leave blank i�not known) <br /> C [/ <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> �r �srai 117 23 �7 R� i�' ��' / r�/ ,G, <br /> GPS LOCATION—decimal degrees(to four decimal places) 1''� / <br /> - Depth Before Sealing � ( ft. Original Depth ft. <br /> Latitude Longitude <br /> UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer r1 /�/►�J <br /> -n,�i h WELL/BORING �vleasured ❑Estimated Date Measured K/T� �JI'tl' <br /> 32�� �'�'sta� �°��' ' � � ,��p� Water-Supply Well ❑Monit.Well f <br /> Show exact location of well or boring Sketch map of well or t�oring J�Env.Bore Hole � <br /> in section grid with"X:' location,showing prop'rtq.,=' ❑Other � ft. �below ❑above land surface <br /> N lines,roads,and buildi gs.,' <br /> � CASING TYPE(S) <br /> --'---—`-----`-----'— <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> � � � � : � l^_lr� <br /> . � , � � i_, <br /> ' ""'""" ""'"-"--"`-- ----- ELLHEAD COMPLE <br /> ' W , ' , ` E� .. TION <br /> v W <br /> �; __�____�_____�_ ___�__ � � Outside: ❑Well House ❑At Grade Inside: ❑Basem�2!"'��D :`. <br /> 'h Miie �4 �itless Adapter/Unit ❑Buried ❑Well Pit <br /> �', ❑Well Pit ❑Buried JUl 0 5 �011 <br /> , S , , _ <br /> F-1 Mile—� � (]Other ❑Other_ <br /> PROPERTY OtWNER'S NAME/COMPANY NAME CASING(S) <br /> �.L1P� ��OT(I�S Diam te� � Depth I Set in oversize hole? Annu ar space ini i <br /> Property owner's mailing address if different than well location address indicated above i �4 <br /> �in.from �/ to__ � ft. ❑Yes �No ❑Yes ❑No L�Unknown <br /> 17W 1a�A�$rA �.�n� �� ir2� in.from ro ft. ❑Yes ❑No ❑Yes ❑No L]Unknown <br /> Plymcxrth, "�"T 55447 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � <br /> t �•u7 <br /> Well owner's mailing address if diNerent ihan property owner's address indicated above Screen frOm_�''�to C J�ft. Open Hole frOm t0 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 /> �'�``� ;.�.� r' �7 <br /> ❑Removed �Not Present ❑Other _ <br /> � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe L�Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to fl. ❑Perfora[ed ❑Removed <br /> Type ot Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �r t � <br /> Grouting Material�L�( ���i�f from � to �� ft. 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 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 /> Tk�n Staiala �+Tell Drillin�; Co�. Inc. 1�91 _ <br /> Licensee Business lyeme License or Registration No. <br /> r <br /> �_ 1 /.'! -'"�i,�F _.f''� / ;� /- 1 � <br /> � - f� � <br /> �rtiGed' presentative Sigifature ' Certilied Rep.No. Date <br /> ti � k <br /> .� ��2�1 ✓ ; �.-; �:.,� ���-..� <br /> LOCAL COPY H � Name of Person Sealing Well or Boring '� J <br /> HE-01434-14 ID#53159 Si�sR <br />