Laserfiche WebLink
! <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> �il[lepiEl Minnesota Statutes,Chapter f03/ or W-series No. <br /> ��ee�e om�+�a oa aw.n� <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constnicted <br /> Orana 117 23 07 ,. ,. ,. — ,�,� ,�j <br /> GPS ��de degrees minutes seconds � <br /> LOCATION: Depth Before Sealing ��� tt. Original Depth ft. <br /> Longitude degrees minutes seconds q IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Bingle Aquifer ❑Multiaquifer <br /> itL�J3 � h Shc�re Dr ��'fJT1Q WELUBORING �Measured ❑Estimated <br /> �(�Vater Supply Well ❑Monit.Well � <br /> Show exad location of well or boring ke h map of well or bonng �,'".�"`-� <br /> in section grid with"X" ation,showing property ❑Env.Bore Hole ❑Other -r"" ft. �below ❑above land surface <br /> N �s,and buildings. <br /> � CASING TYPE(S) <br /> - - - - - -- -i-- �_ <br /> Y ; ,�,1^ u, ❑Steel �lastic ❑Tile ❑Other <br /> �Yo � <br /> W --�- - -- - -- --i-- E ��' � WELLHEAD COMPLETION <br /> f� utsidei'❑Well House Inside: ❑Basement Offset <br /> --�- -;— -;-- --i-- � �� / � _.._—� <br /> �� �J <br /> ❑Pitless Adapter/Unit ❑Well Pit <br /> --;- -�-- -i-- --i-- I / <br /> � f ❑Well Pit ❑Buried <br /> S I <br /> ��""~�' ❑Buried <br /> f}(j ,� ��/�- <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diamet f E Depth , Set in oversize hole? Annular space initially grouted? <br /> Pro n a re' i t t ocation address indicated above 'L� � w.,�' <br /> � in.ffOm.�_ t0��ft. ❑Yes �rvo ❑Yes ❑No ❑Unknown <br /> T <br /> '�� ����i� � in.from to ft. ❑ves ❑No ❑ves ❑No ❑Unknown <br /> Sprin�; Park, t�+,' S53R� <br /> �, _ in.from to ft. ❑ves ❑No ❑ves ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> a / <br /> Well owner's mailing address if different ihan property owner's address indicated above Screen from�_�YO�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �(�lo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YBS ❑ NO Describe �� <br /> FORMATION <br /> If not known,indirate astimated formation log from nearby well or boring PUMP <br /> Type <br /> ❑ Removed ot 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 Pertoration/Removal <br /> in.from to ft. ❑ P+erforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonke=50 Ibs.) <br /> ,/���� / ��/�� � <br /> Grouting Material 1/J`�'�'�[,,,f-����d-�rom�to��4dft. yards �bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The infortnation contained in this report is <br /> true to the best of my knowledge. <br /> dc� St�ala w�ell Drill.ic�; Co,. I�c. i691 <br /> Contractor Business Name License or Registrab'on No. <br /> , , <br /> �� /. <br /> w' � <br /> ,.,., r ff �/''�`���� Ef"'�.5�� <br /> .,��f �"-_ �_,. <br /> A�@ h�o�epresentative Signature Date <br /> LOCALCOPY <br /> H 249110 t� St�rner <br /> Name of Person Sealing Well or Boring <br />