well info - Laserfiche WebLink

Home Browse Search

WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesofa Well and Boring I„I �(,��Q �`ountyNarr� WELLAND BORING SEALING RECORD Minnle9oa�UniqueWellNo. `''� �� ��p f� Minnesota Statutes,Chapter 1031 or W-series No. (Leave Dlank'i�not knownJ Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed Ocvc�o 1I7 23 O7 '' '' '' 2l0 < Ga � GPS Latitude degrees minutes seconds Depth Betore Sealing ft. Original Depth_ _fi. �� LOCATION: Longitude degrees minutes seconds Q IFER(S) STATIC WA7ER LEVEL ��y Numerical Street Address or Fire Number and Ciry of Well or Boring Location ingle Aquifer �MWtiaquifer � ,��'" � WF�L/BORING �vleasured �._Estimated Date Measured�/T��_ - �rWater-Supply Well ❑Monit.Well i Show exact location of well or bonng Sketch map of well or nn — in section grid with"X° location,showing prop ❑Env.Bore Hole ❑Other �R. �below _,�above land surface lines,roads,and buildi gs.� CASING TVPE(S) N �. _''_____'__' _"`"'__`__ �Steel !J Plastic ❑Tile �_]Other __ _ I ----- ----' -' ' -- -- 4,,` WELLHEAD COMPLETION , ' ' '`- a W ; ; : - ` ET �.� _ . �i __;.__ __;__ __�__ ___�__ � Outside: I, �;Well House ❑At Grade Inside: ['��..Basement Offset �� , � � � � '�. � � � � less A p dUnrt ❑Buried ❑Well Pit '�M'� �it da te •' --�-----�--- ---�— --�- I ❑ uned B ' � � S � � L ,-]Well Pit 'r—i Miie—� []Other ❑Other i. P 08 PERTY NER'S NAME/COMPANY NAME CASING(S) 1 Rvan �� ,�o�•�+ Dia1nate�� f Depth r Set in oversize hole7 Annular space initially grouted? � Properry owner's mailing address it diKerent than well location address indicated above �1 � y/� T in.from� to�ft. �]Yes o ❑Yes �'�.No ❑Unknown aPfll7 Q��il� D1Y(1 f �t ��2 . �� y� ee.�`t in.from to h. ❑Yes I ��;No ❑Yes �I No ❑Unknown YM7 aJ,7V't in.from to ft. ❑Yes �_I No f�Yes ;]No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE • � We�l owner's mailing atldress if different than property owner's address indicated above SCreen from_�to�ft. Open Hole from to ft. OBSTRUCTIONS � ❑Rods/Drop Pipe !�]Check Valve(s) [-'��;Debris ❑Fill �lo Obstruction Type of Obstructions(Describe) _ GEOLOGICA�MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes [i'No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. . ( ' � ` �� TYPe �. ❑Removed Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo Annular Space Exists U Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated -��Removed in.from to ft. ❑Perforated �.]Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material��=Q/ �//,1"��or m u ` to �-+ft. yards� bags from to ft. yards bags _.._ from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information wntained in this report - is true to the best of my knowledge. ik�st Stodoltt t+1�I1 Ikilling Co., Inc. 1.69I Licensee Busine s e -�. License or Registration No. ^ ,�- / /' / �� ..�'� �� '-..J t, erC d epresenta roe Signature Certified Rep.No. Date . LOCF,L CCPY H �_._..._.. --�..=, �, .. .r..��'"�..✓ 2 6 4 2 9 9 Name ol Person Sealing Well or Boring HE-01434-10 IC#140-0423 . 5/a�a