|
; WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring I„I ��$� `�j���]�
<br /> County Name
<br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. �� e
<br /> ' �I����� � Minnesota Statutes,Chapter 1031 opaW-serieskNo.
<br /> Township Name� Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
<br /> ()ttxtQ 117 23 46 Nr T� S� � C,� �S
<br /> GPS LOCATION- decimal degrees(to four decimal places) Q �
<br /> Depih Before Sealing /� fL Original Depth ft.
<br /> Latitude _ '-_ Longitude______.
<br /> �IFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �]Multiaquifer . l t�r
<br /> !�� Park Lane, �Q� 55356 W LVBORING �Measured [I Estimated Date Measurec��_[�7�T _
<br /> _Water-Supply Well ,.=MoniL Well /
<br /> Show exact location of well or boring Sketch map of well or oring i�Env.Bore Hole �]Other_ � k. �below ,: I above land surface
<br /> in sectlon grid with`X" location,showing prop rty - �
<br /> lines,roads, i gs���JJJ
<br /> �i N � � CASING TYPE(S)
<br /> f� ��U �Steel �._'Plastic �� �'Tile _.,Other__ _ _ .-,-�C(���\/c�_
<br /> GV �G
<br /> --- - � � '�� WELLHEAD COMPLETION
<br /> W ; ; ; _; ET _
<br /> a �
<br /> ° ' ' ' ; Outside: i._�Well House � At Grade Inside: �,.1 Basement Oftset SEP - 2015 '
<br /> � �
<br /> '/Miie ��� + �pitless Adapter/Unit ��. ;Buried ��1 Well Pit �
<br /> : --,--- --:--- --� - :- 1 � ,_
<br /> ?` �{� 1� _ J Buried
<br /> �� ' , � Well Pit C��1( OF ORON �
<br /> � ' � ;Other � j Other ___ _____,___ '-.
<br /> � �Mue� � — --— — — —
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
<br /> t Diam�t�f O� Dept � Set in oversize hole? Annular space initially grouted?
<br /> �� Property owner s mailing a ress i difterent Ihan well location address indicated above �y in.from to_ ��__ft [�Yes �lo ��,=��Yes ��,�;No L.i Unknown '
<br /> P��• nVE C732 in.from__ �o ft. ;Ves �No ;Yes �]No �;Unknown
<br />- '�� Osseo, A�rtT 55369 '� � ' �
<br /> 1 (�f� 3 _ in trom__ _ to_ _ft LJ Yes ]No []Yes ���Na _'Unknown
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE �
<br /> 1 t
<br /> Well owner's mailing address it ditferent than property owner's address indicated above Screen from��.____._to_�__ ft. Open Hole from to ft.
<br /> OBSTRUCTIONS
<br /> Rods/Drop Pipe �..Check Valve(s) i ,Debris ��Fill '.J No Obstruction
<br /> ' Type of Obsiructions(Descrlbe�.�i" �",�_�._G_=_ a"��/__�'P. _ . ._- _- --.. .___. 4
<br /> T
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes r'No Describe__
<br /> FORMATION
<br /> PUMP
<br /> r� If no known,indicate estimated formation log from nearby well or boring. `7� . ��
<br /> � � �/ � TYPe._ Jv�-- ��� . _ -- � ,'
<br /> � �Femoved �, �,Not Pr sent [�Other_ _. ;
<br /> i
<br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
<br /> No Annular Space Exists I.:Annutar Space Grouted with Tremie Pipe _�.Casing Perforation/Removal
<br /> in.from to ft. f ��perforated r Removed
<br /> T_ in.from__ __ _ _to_. ___ . _.__ ._ft. �.��Perforated ��,��J Removed
<br /> .,� Type of Perforator ��-
<br /> _.-.-_. . __.. .._...__
<br /> �` VARIANCE
<br /> Was a variance granted from the MDH for this well? !_J Yes No TN#.___ _
<br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
<br /> : / t :�
<br /> �' Grouting Material���,��_��from .Q._. to_,�_ ft. . yards_.� bags `
<br /> E. _ -_ - _ —_ -
<br /> � trom__._____ to ft. yards___ bags e
<br /> =i
<br /> �� from to__ .___ fl.__. yards bags ��'
<br /> OTHER WELLS AND BORINGS
<br /> d
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused welt 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 lo the best of my knowledge.
<br /> t
<br /> � Don Stod_ol� t�eell_i�cillirr; CQ, In�--15g1__ _ _-- -- °
<br /> _ _ � •_ _—
<br /> Licensee Buwness lyeme ; . License or Regist�ation No.
<br /> � ' ,,
<br /> �'-" / .�
<br /> ' '" �.' � i� /J
<br /> � _ ,.
<br /> . �,%`�-'f�- � � :
<br /> - = - - - - - - ------ - -
<br /> �d epreS''entative SignaC'ur ' Certilied Rep.No. Date
<br /> .,=� .. ... S, t -�>,..,..:�.,Y1r ,.
<br /> IOCAL COPY H � .J .J l� 1 L _—.- - -- - . ___-- ,- —_ __ �
<br /> Name of Person Sealing Well cr B.ring
<br /> — - - -------- --- - -
<br /> HE-01434-14 IC#140-0423 `� 5�i3a
<br /> �
<br />��.._:-.�...._� ._,,:,, _:�,.�.�...����---=----------.�--. _.. --. � ,. -. :d,p._ . =�. .. u...�....��.��-�_:_. � �,,..-�, ,. � ,.- --"-
<br />
|