Laserfiche WebLink
� �� <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �C���� � <br /> WE��aR BOR�N��o�AT�oN _ WELL AND BORING SEALING RECORD sea''"9"°. i H o <br /> Counry Name Minnesota Unique Well No. - <br /> ����e�rj,�Q Mmnesota Statutes, Chapter 1031 or W-series No. �— � <br /> �L�tleM M iwt known) <br /> Township Name Township No. Range No Section No. Racuon�sm.-►Ig.) Date Sealed Date Well or Bonng Constructetl <br /> 0ttf3!@ 1I� Z Q$ �,�"{�Qj� <br /> Numencal SVeet Adtlress or Fire Number and City of Well or Boring Location r � <br /> 33�� I� Sh+�re 7Jr� Qr(�Q� Depth Before Seahng_�___tt Original Depih �_tt <br /> Show exact location of v.�ell or bonng Sketch map of v,�ll or bonng AO IFER�S) STATIC WATER LEVEL <br /> v <br /> m section grid wrth"X". locay�n.�'Jjsh� property Single Aqwfer � Multiaqwfer <br /> lines,ro36,F a d buildings. ,�/ <br /> ry � WELUBORING L/4Measured ❑ Esfimated <br /> �� E� <br /> - � � � � ❑Water Supply Well �Monit.Well <br /> -�- -�-- --;-- --� � � <br /> • <br /> �,{�k i�rp ��4 ❑ Env.Bore Hole ❑Other _ ft. I�,below ❑ above land surface <br /> �+.rE d <br /> W --�- - -- -i` -- -- E • � CASING TYPE�S) <br /> � � <br /> � � � � <br /> � � �y � <br /> � � � � '-k .�' <br /> -�-- -�-- -i-- --i— � S � ❑Steel �lastic ❑Tile � Other <br /> 3�mile �:� <br /> —�- -�-- -�-- —i— � CASING(S) <br /> Diameter Depth r Set in oversrze hole? Annular space initially grouted? <br /> l� S """��,��� <br /> µ---r mae--�e _��m.from�_ to� tt. ❑ �es (�No ❑ Yes ❑No ❑ Unknown <br /> I I T• <br /> PROPERTV OWNER'S NAME in.from to fl. ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown <br /> Properry owner's maihng aadress d diHerent than well location address intlicated above in.from to R. ❑ Ves ❑No ❑ �es ❑No ❑ Unknown <br /> ����fl i V'$r� B��gg$ SCREEWOPEN HOLE <br /> ���a ���� a� Screen trom_��I_to� fl. Open Hole from to R. <br /> M�tIl3GLC311�8� I'�Q '���1#� � O� � <br /> oesraucnoNs <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Deb�is ❑ Fill ��fVo Obstruction <br /> 7� <br /> Well owner's mailing address if tliHerent Man propeAy owner's address indicated above. TypB of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present �Other <br /> FORMATION <br /> If not known,indicate estimated formatbn log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,Ofl CASING AND BORE HOLE: <br /> Q,Mo Annular Space Exists <br /> �� <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing PeAoration/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to fl. ❑ PeAorated ❑ Removed <br /> Type of pertorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 Ibs.) <br /> Grouting Matenal���„�iG6m � ro�_ ft. yartls �_ bags <br /> from lo ft. yards bags <br /> from to ft. yards bags <br /> from to—_ k. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALIHG OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on propeAy? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in Mis repoA is <br /> true to the best of my knowledge. <br /> l)O� �'tedel� �d�l l t')ri�t tr,�(;A. $.'E.� t 7� <br /> Confracror eusmess Name �`icense or A �s a. <br /> '� `' �� '� 5-3I-�t?0 <br /> Au orized Represenfative Signature Date <br /> .Ti� Antonson <br /> ����� lb p� � ����� Name o/Person Sealing Well or Bonng <br /> H <br />