HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 0 5 9
WELI OR BORING LOCATION
CountyName WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
(- �\,f (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date bYell or Boring Constructed
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'/a / '/a �, _ A C:,� :�� ���f � � .
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Numerical Street Address or Fire Number and City of Well Borin Location
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�. � � , � � � Depth Betore Sealing � ' ft. Original Depth (� ft.
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Show exact location of well or boring Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property Single Aquifer ❑ Multiaquifer
lines,roads,and buildings. �O
ry WELUBORING [�Measured ❑ Estimated V �' � ,
' ' ' ! ;�,. � �'';. N � � ['�,'Water Supply Well ❑Monit.Well ��� ����
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- -r- - - --�-- -- _.—". �
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I � � � �"�--- ❑ Env.Bore Hole ❑Other ft. �below ❑ above land surface
W --�- -�-- -'-- --";-- E N�1'� � CASING TYPE(S)
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i _.�^—���
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—�- -�-- -�-- ---I-- �,,. j';`'� [�„Steel ❑ Plastic �Tile ❑Other
� � � '/mile �P h1_'j
' ' ' ' � - i CASING
—�- -�— --�-- ---I-- � �
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t Diameter Depth Set in oversize hole? Annualar space initially grouted?
I� S �J� �� in.from�_ to �� ft. ❑ Yes [�No ❑ Yes ❑ No �Unknown
pk—1 mile�ie —..v
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PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown
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Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
� �-r'�k
�'� - � Screen from to ft. Open Hole from to ft.
OBSTR UCTION/DEBRIS/FILL
WELL OWNER'S NAME r �'Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
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Well owner's mailing address if di8erent than property owner's address indicated above. Type of Obstruction/Debris/Fill 1 �� ' t_�+ ! �- .1 �.
Obstruction/Debris/Fill removed? Yes ❑ No
PUMP
TyPe i �
3
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed [y`� Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby wall or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� No Annular Space Exits
1�
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.trom to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
Grouting Material �,� �'� �'i�. �' from (: , to !� �-� ft. yards � bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORWGS �, ., : k.. �� � .
� �,}� t` .
Other unsealed well or boring on property? Yes ❑ No
�1 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
��'` �.
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.
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Contractor Business Name License or Registration No.
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Authonzed Representative Signature Date
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o� � Name ol Person Sealing Well or Bonng ��
LOCAL COPY H ! � O �..� � �
HE-01434-02 10/95R