Laserfiche WebLink
BORING LOCATION MINNESOTA pEPARTMENT OF HEALTH Minnesota Well and BoringSealing <br /> I I y i'�j <br /> .,ounty Name 'i <br /> WELL AND BORING SEALING RECORD MinnesoaoUniqueWellNo. a� �jV <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) <br /> Township WirT Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> ..r <br /> 00 <br /> GPS Latitude degrees minutes____ seconds Depth Before Sealing 4Q 7 ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes_ seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /y <br /> W LLIBORING Measured [_]Estimated Date Measuredc /'`'/ <br /> Water-Supply Well ❑Monit.Well 01 <br /> Show exact location of well or boring Sketch map of well or boring- <br /> in <br /> �/) <br /> in section grid with'X" location,showing property ❑Env.Bore Hole ❑Other U.-Oft. below ❑above land surface <br /> N066 dings. CASING TYPE(S) <br /> i---------------- <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ""i""""" """" """" "" T WELLHEAD COMPLETION <br /> W E <br /> I <br /> ,ti Outside: E]Well House ❑At Grade Inside: ❑Basement Offset <br /> Mlle .�� Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> r 1 <br /> ❑Well Pit <br /> LJ Buried <br /> S ❑Other <br /> 1 Mile Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diem r Depth f Set in oversize hole? Annular space initially grouted? <br /> Propertyo s mai ing address rf v erent t an wel ocatlon address indicated above �- <br /> in.from to/ ft. ❑Yes No ❑Yes ❑No ❑Unknown <br /> Sam 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 /> /P.-7r, <br /> t r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from f�r to�ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill X No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes [-]No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <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 Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) <br /> Grouting Meter' rom tJ917 ft. 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 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 /> Don Stodole Well Drilling Co. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> C e entative Signat Certified-Rep.No. Date y <br /> 285100 <br /> �^ ^ <br /> LOCAL COPY H /8 5 1 O f VV 1 Name of Person Sealing Well or Boring <br /> HE-01434-11 IC#140-0423 L�VV ; j 21088 <br />