Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H y 281800 <br /> 1 WELL AND BORING SEALING RECORD SMinnesota lng oUnique Well No. <br /> County Name <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> HerinePin (Leave blank if not known) <br /> Township Name Township No. Range No.Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> On so 117 23 09 NE NE NE `-/ A 09 <br /> GPSu de es �_ to seconds /Depth Before Sealing 02 ft. Original Depth ft. <br /> LOCA _ O IFER(S) STATIC WATER LEVEL <br /> Numerical Street reet Address or Fire Number*and City of Well or Boring Location ( Single Aquifer ❑Multiaquifer <br /> 1000 Old Crystal Ba Rd S W UBORING Measured ❑Estimated Date Measured 5em� /AY <br /> sWater-Supply Well ❑Monit.Well t <br /> Show exact location of well o5W17.. Sketch map of well or..'•• <br /> in section grid with"X." location ' . . ..erty ❑Env.Bore Hole ❑Other ft. 'below ❑above land surface <br /> , oads, nd buildings. <br /> N CASING TYPE(S) <br /> yIP Xteel ❑Plastic ❑Tile ❑Other <br /> ---i------'--------------- 1 �► .................""'""' ‘Wit W HEAD COMPLETION <br /> w E1. <br /> __ I <br /> r ' ___ '- side: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile- itless Adapter/Unit ❑Buried ❑Well Pit <br /> 1 ,. <br /> ❑Buried <br /> '�, <br /> ' r ❑Well Pit <br /> S ❑Other <br /> I-1 Mile- I -_ ‘......+"'"- ❑Other <br /> PROPERTY R'' <br /> OWNESSyN2AME/COMPANNY NAME CASING(S) <br /> Robert Elizabeth Melamed Dianme}[�� 'l m f Depth f Set in oversizersizhole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above - Y in.from CJ to ft. ❑Yes No 111 Yes El 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 rr���} <br /> . Well owner's mailing address if different than property owner's address indicated above Screen from ce f to /V 2 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris U Fill ) o Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR 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 /> ^Y. /► Type <br /> '~� <br /> 1. / ❑Removed Xlot Present ❑Other i <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> r 'No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing 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 lbs.,onebagof bentonite=50 lbs.) <br /> Grouting Material V <br /> from 0 to ! � ft. yards bags . <br /> 104 <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)(lo 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 Stodola Well Drilling Co,. Inc. 1691 <br /> Licensee Business Na License or Registration No.y. 8- y Q l <br /> 'fir ifi Representative Signature Certified Rep.No. Date <br /> COPY H 281800 — <br /> Name of Person Sealing Well or Boring - - <br /> HE-01434-11 IC#140-0423 281800 )—w--- <br /> Name 2/08R <br />