Laserfiche WebLink
• ` MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring +� ")'�/'��� � <br /> WELL OR BORING LOCATION S@811f19 NO. II H j � � <br /> �o���Y Name ---- — WELL AND BORING SEALING RECORD M;��esota u��q�e wen No. r ----- -- <br /> Minnesota Statutes,Chapter 1031 or W-series No. I - - I <br /> e�ne�pin �,�.a�,k n��k�,�, �- _J <br /> Township Name�.Townsh�p No �Range No�Sect�on No Fracuon fsm -s Iq.) Dale Sealed Date Well or Boring Constructed <br /> I I �*� � � � <br /> —v-LL_� - <br /> Numerical Street Adtlress or Fire Number and Ciry of Well or Bormg Location Q � � <br /> Depth Before Seal:ng t�„�N O�iqinal Depth �� n. <br /> Show exact location of well or bonng Sketch map of we�l or onng AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location. showing pr perty Single Aqwfer ❑ Multiaqwfer <br /> lines,roads,and build gs.. <br /> N WELUBORING Measured ❑ Estimated <br /> ','� � � � � Water Suppry Well ❑Monit.Well � <br /> \ � ❑ Ern.Bore Hole ❑Other _ ft. �below ❑ above land surtace <br /> l <br /> �� W -�- -i-- -i-- --i— E CASING TVPE�S) <br /> � � � � ^� <br /> . , , � <br /> ' -;-- -;-- -;-- --�-- � (((��-�\\\���� Steel � Plastic �Tile � Other <br /> � � I I Ylmile F+ <br /> —�- -�-- -1-- --�-- � 1� CASING(S) <br /> --�,R i� Diameter Depih � Set in oversize hole? Annular space initially qrouted7 <br /> S • !t 1� <br /> 4 „�;�—�, `� � in.from.�_ to� tt. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I <br /> PROPERTY OWNER'S NAME in.trom to tt. ❑ Yes ❑ No ❑ �es ❑No ❑ Unknown <br /> � w <br /> Property owner's mailing address B diflerent than well location address indicaled above. m.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> '� Q+�' f <br /> Screen from�_to��� ft. Open Hole from to R. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Dro Pi l� <br /> ❑ p pe ❑Check Valve(s) ❑Debris ❑ Fill yp No Obstruction <br /> I� <br /> Well owner's mailing address if diflerent ttian property owner's add�ess indicated above. Type o(Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> OEOLOOICAL MATERIAL COLOH HARDNESS OF FROM TO � Removed Not Present ❑ Other <br /> FOHMATION <br /> if not known,indicate estimate0lormatan log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> . � , <br /> o Annular Space 6cists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> � in.from �o n. ❑ Pertorated ❑ Removed <br /> in.from �o tt. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> < ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> f <br /> GrouGng Material rom _� to�� ft. yards _�_ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to__ R. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS ��T <br /> Other unsealed and unused well or boring on property? ❑Yes c How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> � This well or bonng was sealed in accordanca with Mincsso'a��.,�e�.Chanter a72` 1'�e IMorrriatio^ <br />