Laserfiche WebLink
WELL OR BORiNG LOCanoN MINNESOTA DEPARTMENT OF HEALTH Seai ng NoWell and Boring '„' <br /> � CountyName WELL AND BORING SEALING RECORD Minnesota Unique WeII No. <br /> Minnesota Statutes,Chapter f031 or W-series No. <br /> ��ee.-e oia�n�a m�..�> <br /> Towns ip a Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> nr 17 2.3 07 ��8 '. � <br /> GPS Latitude degrees minutes seconds + <br /> LOCATION: Depth Before Sealing ���ft. Original Depth ft. <br /> Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring location Single Aquifer ❑Multiaquifer <br /> * ELUBORING �Measured ❑Estimated <br /> �31� �Ct�l shore Dr Q� 553fi4 ater Supply Well ❑Monit.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 � ft. �low ❑above land surface <br /> e roads,an���uuu ildmgs. <br /> N ,� ,, `` `��,�,� !',� , CASING TYPE(S) <br /> y1ti4 ���.L <br /> �Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - - -;-- --i-- E WELLHEADCOMPLEIION <br /> � � � ��� Outside: ❑Well House Inside: ❑Basement Otfset <br /> -;r- ---- -;-- -i-- <br /> � 1�� � ❑Pitless Adapter/Unit ❑Well PR <br /> --,- -�- -�-- -i-- � "" �41 �-- <br /> � �/Jell Pit ❑Buried <br /> S <br /> �"-�'"N-�' ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter � Depth � Set in oversize hole? Annular space initially grouted? <br /> Prope owner s mai ing a ress erent tha wel ocation a dre s�in icated above (��t � <br /> � In.ffom � to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> - in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAMEJCOMPANY NAME SCREEN/OPEN HOLE <br /> f + <br /> ��,(' � <br /> Well owner's mailing address rf difterent than property owners address indicated above Screen from �� t0 ���ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> 1�Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)�- �� �`£N�F/P �,�"T/� _"';�'f Ff'!� p �i�Xj/J <br /> HARDNESS OR �G�� <br /> GEOLOGICAL MA7ERIAL COLOR FORMATION FROM 70 Obstructions removed? Yes ❑ No Describe <br /> If not known,indicate estimated fortnation log from neaiby well or boring PUMP <br /> � ��J TYPe �� RG✓� �Cll7� �% <br /> �`Removed ❑ 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 of pertorator <br /> O Other <br /> GROUTING MATERIAL(S) (One bag of cement=94�bs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material ���� ` ���vffrom ` ro �`� ft. yards �51 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 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 is <br /> true to the best of my knowledge. � <br /> I)on Stodvls �tell I�ri22i � Co., Inc. 2T172 <br /> Conhactor Business me License or Registration No. <br /> �' ,o�. /.� o� �.� <br /> present rve Si hire Date <br /> t� <br /> LOCAL COPY H Z����� T'�rl.�,,, `.,��,/�✓{1�Y�.Q.tf`t'w�-' <br /> Name o�Person Sealing Well or Boring <br />