|
WELL OR RORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 2 7 9� 7
<br /> WELL AND BORING SEALING RECORD Sealing No.
<br /> County Name Minnesota Unique Well No.
<br /> '!@rlTl�' �il Minnesota Statutes,Cha ter 1031 or W-series No.
<br /> � P �,aa�e e���k���o�k�ow,�,
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed . Date Well or Boring Constructed
<br /> (?rono 217 23 09 S�T° � ,'�T {��
<br /> ,. GPS LOCATION- decimal degrees(to four decimal places) � �e
<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 Li Multiaquifer w��/
<br /> 31fi0 Nocth St�wre Dr, �ro� 55391 WELVBORING �easured ��_Estimated Date Measured���� *V-I/'
<br /> �: �Water-Supply Well ',_;MoniL Well R, • %
<br /> - Show exact location of well or boring r Goring � , � ��,
<br /> ' in section grid with"X" location.showing operty i Ern.Bore Hole I ]Other ft. �below ,._J above land surface
<br /> _....-----. _
<br /> N lines,roads,and b Idings. CASINGTYPE(S)
<br /> , '-- � `- '--
<br /> � �LHEpL]Plastic '���Tile J Other
<br /> teel �
<br /> � _-_-- -----__. ,
<br /> --- - -- � �� --
<br /> � D COMPLETION
<br /> : W ; ; ; ; ET _
<br /> `� � � � � Outside: ', ,Well House ���,. i At Grade Inside: ��Basement Offset '�
<br /> .�°� , , , r Miie dless A p r/Unit �. 'Buried ...Well Pit
<br /> � / r
<br /> , , , , � �P' da te � �i.
<br /> --�-- -�-- --�----�- - �
<br /> � � 5 � �
<br /> ��Well Pit C Buried
<br /> f--i nniie—� I/�__ L/ `�� _�� _I Other __ �Other _
<br /> /if�7'����,.. G.7��
<br /> PR�O,r�PEt�RT_Y O`W.�NERyS NAME,%COMPANY NAME CASING(S) �i.
<br /> L'J1A�c rr��li�(,.'� DiameIer De th � � ��
<br /> �j�� . p � Set in oversize hole. Annular space initially grouted.
<br /> Properry owners mailing address if ditferent than well location address indicated above �C! in.from� to_��.�_ft. � ]Yes ���I No ❑Yes ll NO �
<br /> f ,� �� �u Unknown
<br /> ; __._in.from to __ft. �_I Yes ' j Na ❑Yes ❑No U Unknown :
<br /> ____,_in.from to ft. ���.. �.Yes `.J No [�,Yes L�No �_]Unknown �
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � �
<br /> � r
<br /> r� Well owner's mailing address it ditferent than property owner's address indicated above Screen from__�,�A�_ _to ft. Open Hole from to fL ��'
<br /> _ _ �_-_ _..- -. .__
<br /> OBSTRUCTIONS
<br /> �]Rods/Drop Pipe � �Check Valve(s) '_1 Debris �_ .Fill �o Obstruction
<br /> `: Type of Obstructions(Describe)_ '
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? i�-1 Yes [j No Describe
<br /> FORMATION
<br /> PUMP
<br /> If not known,indicate estimated formation log from nearby well or boring.
<br /> : TYPe—____ _
<br /> J� �.Removed Not Present ❑Other
<br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOfiE HOLE:
<br /> No Annular Space Exists '�.`]Annular Space Grouted with Tremie Pipe ��-1,Casing PerforatioNRemoval ��
<br /> __ _,_ in.from_ ___ to__ _ft i_�Perforated ;J Removed
<br /> ` in.from to__.. ft. �, �Perforated I.J Removed
<br /> i - —
<br /> Type of Perforator
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �'Yes o TN#
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> � 1 t
<br /> GroutingMaterial � {� f�i�,r�t�� from_ U_ __ to ��� ft._____ yards��� bags
<br /> -' _ from to___ ft. yards bags '
<br /> __ __ from _ to ft.___ ya�ds_ _ bags
<br /> OTHER WELLS AND BORINGS
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? I,_ ,Yes � �.No 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 Ihe best of my knowledge.
<br /> 1�fitodola�t lI _���in��slc�._�4L ,
<br /> Licensee Business Name � License or Registration No.
<br /> %`�' � ` /� � `�'- ��
<br /> C �i senfa�ve SignatUre Certilied Rep.No. Date
<br /> _ ��
<br /> �' LOCAL COPY H - - -���� ���
<br /> :�2 7�7 7 -- - --------
<br /> Name of Person Sealing Well or Boring
<br /> HE-01434-14 IC#140-0423
<br /> .,,.. 5/13R
<br />
|