Laserfiche WebLink
wELL Of1 BORN�G LOCATiON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bonng �H �41518 � , <br /> WELL AND BORING SEALING RECORD Sea6ng No. <br /> �� - - <br /> H�nne lIl Minnesota Statutes,Cha ter 1031 Minneso;a Unique No. <br /> F p or w-senes No. I <br /> ILeave blank�I nu�known) J <br /> TowrWiq Name Townshlp No. Range No Section No. Fracnon�sm.-i Ig.) Date Seaied Date Well or Boring Constructetl <br /> Ix'c�CRCiNG ? i 7 11 t1$ ,. , �f�? � <br /> Nixnencal Street Address a Ffre Number and Clry of Well or Bonng Locatlon � / <br /> �`i C%� Alarthshc:�I'�P_ QZ 1.4'E L+r�I20� MI QeDtFr�C°�'��i�"9 �,,,"'�,o�j N Original Depth ��� n <br /> Show exatt bca6on d�rell or boring , Sketch map of well or bor�ng UIFER(S) STATIC WATER LEVEL <br /> in section grid whh'X'- locahon, showmg property Single Aywfer � Multiaqui}er <br /> _ lines,raads,and bulldings. <br /> N � WELUBORING Measured ❑ Es6mated <br /> . ! Water Supply Well ❑Monit Well r <br /> —'�_�.� ��r, <br /> ' , ❑ Env.Bore Hole ❑Other _ _�tt. �bebw ❑ above Wnd surtace <br /> W 'T' 'T' 'Y' 'l" E 1 � .� ; CASING TVPE(S) <br /> . � � � ! � �� <br /> -�'- -r- -i-- -�-- � F j .,.. � �Steel � Plasfic �Tile �Other <br /> � � i i u m�le � �._.�__ _... <br /> _�_ _'_ ' ' � I CASING <br /> + -i-- -�— c_ _..___. <br /> Diameter Depth � Set m oversize hole9 Annualar space inrtially grouted7 <br /> ll�� ..._.�...... .._._._._..__._ ___ _.__ / �/ � <br /> �(�—imis� . � ,,,�1' �/ in.from � to 5�+� tt. ❑ Yes �No ❑ Yes ❑No ❑ Unknown <br /> I �`. <br /> PFiOPERTV OYIMER'S NAME in.from to fl. ❑ Yes ❑No ❑Yes ❑No ❑ Unkrrown <br /> �{�.� �.'.1��.�'�i�� <br /> Prape'ry ownel's mairg adOress if AiNerent than well location adtlress indlcated above. in.from to tt. �❑ �es ❑No ❑Y� ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> 1 / <br /> r <br /> Screen from ��� to� ft. Open Hole from to k. <br /> OBSTRUCTIONS <br /> ���'���E Rods/Dro Pi <br /> p pe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstructbn <br /> YYM ow�els meip address if difterent than propeAy owner's address irWicated above. Type of ObsVuctions(Describe)i//l��-f f�� ��`'_ � �j �� <br /> Obstructions removed?�Yes ❑ No Describe <br /> PUMP <br /> TYPQ J�� /7vrr��� <br /> (iEOL.OQIC�L YATFJMAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> M nol b�,ndce`esEmabd fom�a6on log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE: <br /> ; �No Annular Space Ezits <br /> - ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Pertoration/Removal <br /> in.from to ft. ❑ PeAaated ❑ Renaved <br /> in.from to ft. ❑ Perforated ❑ Rertioved <br /> Type of peAorator <br /> ❑ omer <br /> GROUTING MATERIAL(S) <br /> �`` y <br /> GroutingMaterial �.-+f"�'�'�`^`���'°-�from '�� ro�r� (t. yards � begs <br /> from to tt. yards bags <br /> from to fl. yerds begs <br /> from ro__ It. ysrds baps <br /> Ii�ANLS,901MICE OF DATA,dFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Olher unsealed and unused well or boring on property? ❑Yes No How man� <br /> LICENSEO OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boting was sealed in accordance with Minnesota Rules,Chapter 4725. The iMamation oontained in Mis repoR is <br /> true to the best of my knawledge. <br /> L`C;N S'i'UI?U� k'�;LI., DRI:.LI�i� Ct?. , 1NC. �:71"12 <br /> Confrector Business Name ;!=��+� licw�se a Repisha0on�:o. <br /> ,�`'/ � t <br /> orized epre ntative Signeiure Drps <br /> ,:-- <br /> �. <br /> H ������ Name ol Persan Seqling Well a Bori� - <br /> LOCALCOPY <br /> FE-01�34-03 2/97 q <br />