HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring I„I � ���� �
County Name
WELL AND BORING SEALING RECORD MinnesoNa Unique Well No.
5 Minnesota Statutes,Cha ter 103I or W-series No.
���}�p��M P (Leave blenk�it not knawn)
114 i�
Township Name Township No. Range No. Section No. Fraction(sm.-»Ig.) Date Sealed Date Well or Boring Constructed
�'�cona l.l? 7.3 ?1 SF ?'�i !+��T d
GPS LOCATION- decimal degrees(to four decimal places) /� �
Depth Before Sealing ��/ ft. Original Depth ft.
Latitude Longitude __
UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ' Single Aquifer ❑Multiaquifer /��yv
7/,7fi ��,.� n��C� [>,.� (rC.��� ��'�n� W UBORING Measured ❑Estimated DateMeasured��l� �)/T!
� � Water-Supply Well ❑Monit.Well t � �
Show exact location of well or boring Sketch map of well or boring �
in section grid with"X" location,showing property U Env.Bore Hole ❑Other ft. �below ❑above land surface
N -� lines,roads,and buildings. CASING TYPE(S)
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; �teel ❑Plastic ❑Tile []Other
--'--- --�------�-----+-' �� ELLHEAD COMPLETION
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�Y� � W
W : ; ; � ET ' : � _
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� � _;__ __�__ � ?a� I Outside: ❑Well House ❑At Grade Inside: �Basement Offset �
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'h nni�e �—" ❑Pitless AdaptedUnit ❑Buried ❑Well Pit
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__'___ __�______�_""_"`_" ..
1 ❑Buried
' S ' f! ❑Well Pit
❑O[her
, i M�ie� ___/` ❑Other
PROPERTY OWNER'gt,�NAME/COMPANY NAME CASING(S)
�t t � �Q''���n Diamete�� r Depth t Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it diHerent than well location address indicated above �in.from_� to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
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Well owner's mailing address if different than property owner's address indicated above Sc�BBn from_�_to__���ft. Open HOIe from to ft.
OBSTRUCTIONS
ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
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TypeofObstructions(Describe).,,�/V1�/+�� /"1� 9- �f�f
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑No Describe
FORMATION
If not known indicate estimated formation log from nearby well or boring. PUMP �^�,
� i TYPe � " t ��'1�
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✓ �emoved ❑Not esent ❑Other
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� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
[�lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes No TNtI
GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite-50 Ibs.)
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Grouting Material �iG�`i���rom�� to�_�ft. yards�__ bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS ��
HEMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
RECL11/�� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
�UI� o � �016 �'� �to�iola Fl�ll I�rillin;� Co, Inc. Ih�l
Licensee Busine�ss Name License or Registration No.
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�IT�'OF ORONO `�� . �-' �' � 1 (�a
C 'i �fi p 'sentahve Sign r Certified Re p.No. Date
H � � �*'1 tv � � '.��� w-"a ' ��._.,. �: �, ��I��)V'v.
LOCAL COPY •✓ �..3°�� � Name of Person Sealing Well or Boring f
HE-01434-14 ID#53159 5n3R
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