Laserfiche WebLink
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION ali9 H 268214 <br /> CtAxriy Name•' <br /> 1NELL AND BORING SEALING RECORD Mi peso a Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> O..dank x not known) <br /> Township.Name Township No. Range No.Section No. Fractior(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> fteno 117 23 7 3200021'A at Ff. 0 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing /? ft. Original Depth ft. <br /> LOCATION: Longitude degrees_ minutes seconds <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Ingle Aquifer 0 Mukiaquifer WMeasured <br /> oRING ZI}Measured ❑Estimated Date Measured 5 /� 1 <br /> Show exact location of well or boring Sketch map of well or boring 7star-Supply Well 0 Mont.Well ‘/ <br /> in section grid with"X." location,showing property ❑Env.Bore Hole 0 Other Y n. 'elow ❑above land surface <br /> N ,�i islines and Ings., CASING TYPE(S) <br /> )(Steel ❑Plastic ❑The 0 Other <br /> i f WELLHEAD COMPLETION <br /> w ET <br /> I__• I fr <br /> Outside: 0 Well House 0 At Grade Inside: 111(lasement Offset.. <br /> 1 Mile ❑Mess Adapter/Unit ❑Buried <br /> ❑Well Pit <br /> ❑;Well Pit ❑Buried <br /> 1 <br /> me-� 111 Other <br /> ❑Other <br /> P PERTYNA COMP AME CASING(S) <br /> Dier7�etpre t Depth (� a Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address If different than well location address indicated above y in.from ' to/2 t7.:. ft. <br /> 0 Yes No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes 0 No 0 Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes 0 No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owners mailing address If different than properly owner's address indicated above Screen from-f r. to r ft.' Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris 0 Fill AI No Obstruction <br /> Type of Obstructions(Describe) <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION PROM I TO Obstructions removed? ❑Yes 0 No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> LI ❑Removed ANot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Annular Space Exists ❑Annular Space Grouted with Tremie Pipe 0 Casing Perforation/Removal- <br /> it from to ft. ❑Perfdrated 0 Removed <br /> in.from to ft. ❑Perforated 0 Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIALS) (One bag of`cement ee 94 lbs.,one bag of bentonite Jet)lbs.) <br /> /ZZs r V <br /> Grouting Material i.e'�rC/1t')7 om 69 to/13Z ft. yards bags <br /> from to ft. yards bags <br /> frofn to ft. yards: bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed unused well or <br /> boring on <br /> 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 /> • <br /> pan ala WealCe., Inc- 1491 <br /> Licensee Business Name License or Registration No. <br /> •epresentative Signatu'-' Certified Rep.No. Date <br /> LOCAL COPY H 268214 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 5/078 <br />