Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring �„� � d9 `� ��(1 <br /> County Name <br /> WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. `'+ -i l'' <br /> T� Minnesota Statutes,Chapter 103I or W-series No. <br /> ';C���7 �❑ 0.eeve dznk�i oo�enown> <br /> Township Name Township No Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> ��'OTtQ 11�` 2� r?e ,�.'1 �r�r Slar ,�7 I�D <br /> GPS LOCATION-decimal degrees(to four decimal places) / I - <br /> Depth Before Sealing �!� ft. Original Depth ft. <br /> Latitude Longitude_ <br /> . IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �6ingle Aqui(er ❑Multiaquifer A �/ <br /> .,rt I�1 ?�?orth �hore nf� Q�OTin 553�� WELL/BORING Measured ❑Estimated Date Measured��"�J� 1,� 1 <br /> �� Water-Supply Well ❑MoniL Well � <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X:' location,showing property Env.Bore Hole ❑Other _��__R. �below ❑above land surface <br /> lines,roads,and buildings. <br /> � N CASING TYPE(S) <br /> - --'-----i-----`-----'-- r----'-._—_. <br /> �teel ❑Plastic ❑Tile ❑Other <br /> "'-""�"'"'�""''" WELLHEAD COMPLETION ' <br /> W : ; ; ; ET <br /> � � � � --- Outside: []Well House ❑At Grade Inside: ❑Basement Offset <br /> � � � � <br /> 'h Mi�e � �=� �Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> --:-----; � ; 1 . <br /> r-- ----------- <br /> - ❑Buried <br /> 5 ' ❑Well Pit <br /> ❑Other <br /> �i Mi1e� � ❑Other _ <br /> �J.,,,.c:.�.. �_�, .��. <br /> PROPERTY O1WNER'S NAME/COMPANY NAME CASING(S) <br /> C�[� �nil S�n Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Properiy owner's mailing address if different than well bcation address indicated above ��. <br /> '� in.from� to_��,�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME � .. . _ ., , SCREEN/OPEN HOLE <br /> ' � .� ' �` � ; / / <br /> Well owner's mailing address it different than property owner's address indicated above Screen from1��t0 1f 4 k. Open Hole from to ft. <br /> C��l� F.i� � � �.,'„� �'t:,� �TFiUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)�L�� 4 L��� <br /> GEOLOGICAL MATERIAL COLOii HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe <br /> FORMATION <br /> PUMP ` <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> v_�y ` � v ��� Type <br /> t_.�_. <br /> ❑Remaved �Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated �]Removed <br /> Type ot Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 Ibs.,one bag of bentonite=50 Ibs.) <br /> , � <br /> Grouting Material�.�%��� from � to_��� ft. yards� bags <br /> from to tt. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES tN SEALING Other unsealed and unused well or boring on property? ❑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 the best of my knowledge. <br /> �on �tQ�ola �Jell nrilling Cfl,. Inc. 1b91 <br /> Licensee Busi�ss Name License or Registration No. <br /> �''` i/_ �7 <br /> `'r��� ,/�� ' �/ ;..,.� " ��� 1 l.c <br /> eRffi�d Re resenfative Signatur � Certified Rep.No. Date <br /> ! — <br /> 3�1��0 ��.._ �`"�_..�,,_�.��_,,,�._.�-._ . <br /> LOCAL COPY H ���`� <br /> Name ol Person Sealing Well or Bonng , � <br /> HE-01434-14 ID#53159 .. 5��3q - <br />