well info - Laserfiche WebLink

Metadata

Thumbnails

Annotations

WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Weli and Boring H � ��4 5 3 County Name WELLAND BORING SEALING RECORD Mnnesoa�UniqueWellNo.� e! Minnesota Statutes,Chapter]037 o�W-series No. p �c':! .$�. 0.eave war�n nm knovn,� �Qsa�.� — — ot 6m Township Name Township No. Range No. Section No. Fraction(sm.-•Ig.) Date Sealed Date Well or Boring Constructed �Can� 2I� 2� Cll S� SE S� �."�.,. 4 ""� �;j,�'`'� !1 .,�;�r GPS LOCATION- decimal degrees(to four decimal places) ['� � . ." '` Depth Betore Seating �l�� ft. Original Depth g. Latitude Longitude ,, � IFER(S) STATIC WATER L L '�+'✓= , � � � Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer ' ' � rvf An �� '��nr A^►..,.r,., WELUBORING �teasured ❑Estimated Date Measured S�_ s _�,t�r ��Y� 4�suRiV Water-Su I Weil pp y ❑Monit.Well c`,�� Show exact location of well or boring Sketch map of well or boring Env.Bore Hole in section grid with"X:' loc tion,sh�, gpraperty ❑�her +"� ft. �below ❑above land surface N ,roads,ar)p3bwi ng�. CASINGTYPE(S) ..!✓f ..sc.. --�----i----�-----�-- � �Steel ❑Plastic ❑Tile ❑Other --=-----=-----`-----�-- � WELLHEAD COMPLETION W : : ; ; ET ' � _ �_____�____�_____�__ Outside: ❑Well House ❑At Grade Ineide: ❑Basement Offset 'h Miie ❑Pitless Adapter/Unit �uried ❑Well Pit --:-----r-- ---------=-- 1 ❑Weil Pit ❑Buried , � S � � _ _� ❑ __....., ,A,.___ � -- ther �t Miie�.. -� � � Y''� ❑Other � a �> ,(;:_s►..,, P�R+OPERTY OW�+N�ER'�S NAME/COMPANY NAME CASING(S) 1+� �.�G�� Diameter � Depth � Set in oversize hole? Annular space initially grouted? Property ow�er's mailing address if diHerent Ihan well location address indicated above I��, � �in.irom�_ to�_ft. ❑Yes No ❑Yes ❑No ❑Unknown r��,.��+� ��T� g in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 1'.V�21UZ A7R��,j C�:� ��.7� in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE t f Well owner's mailing address if different ihan property owner's address indicated above SCreen ffom�_to��ft. Open Hole from to ft. OBSTRUCTIONS �ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions{Describe)�it)`r�J�� f'"„{f"Y � 1./�r GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? [�es ❑No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP �iL �,+ [�t TYPe ❑Removed �lot Present ❑Other M�OD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to R. ❑Perforated ❑Removed Type of Perforator VARIANCE . . Was a variance granted from the MDH for this weli? �Yes o TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonke=SO lbs.) � �g r +� Grouting Material��i�� from � to T�� ft. yards '�*�" bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORWGS 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 contained in this report is true ro the best of my knowledge. I1o�t Stt�fll� tdeil�ri3lit� �,. �I.t�. llag�. Licensee Business Na�ne ,, � r- License or Registration No. ,.� .`'` � j'' P ( ." _-Xf'' �'_ �`''� r"-��y.!'�... .. � � ',�T /,��1``� '�."''' -+F'�f Y'" �'�`�� C, �iezl R�irt2�$�gnature Certilied Rep.No. Date " 329453 J�' �''°� LOCAL COPY Name o/Person Sealing Well or Boring HE-01434-14 IC#140-0423 5/13R