HomeMy WebLinkAboutwell info � MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. H � � ���� �
County Name Minnesota Unique Well No.
Minnesota Statutes,Chapter 103I or W-series No.
r7enna=�in «ea�a b�a�k,,�o,u�ow�,
r Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Orona 117 23 17 *3'� !�7 tJ�l Z !� /
. ;
GPS Latitude__,_ degrees__ minutes seconds Depth Before Sealing 2�� ft. Original Depth ft.
" LOCATION: Longitude___ degrees.__ minutes seconds
�UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �]Multiaquifer .�n ��- j
1h�d5 .�y�!� (�3 T�C� !����fl S��C�� W VBORING �Measured [j Estimated Date Measured J�"�m� ,�/'�'
� \'�� �Water-Supply Well �]Monit.Well j
Show exact location of well or boring Sketch map of well or b ing- �
in section grid with"X" location,showing prope y . ❑Env.Bore Hole ❑Other _ ��__ft. �below ❑above land surface
N lines,roads,and buildin s. CASINGTYPE(S)
�� -'--- --'--- '--'---'--
i � �Steel ',�Piastic � I Tile �I Other_ .
� � , � , .
--'�----'--- ---`-----'-- •WELLHEAD COMPLETION
W ; : ; ; ET x
,
� � � � - ' ,9ptside: ❑Well House ❑At Grade Inside: ❑Basement Offset b
-- �
'h Mile t I�L ❑Buried ❑Well Pit �
i Q f . ��Pitless Adapter/Unit
3 1 ' ❑Well Pit ❑Buried
; ; S ; ; +>.✓ ,. ❑Other
�--1 Mile� ' ��f ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
�[� ,__ Diam t�� � Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it ditferent than well location address indicated above �"'�in.ffOm� to ����ft. ❑Ye5 �No 'i_ �Yes ❑No ��Unknown
in.from to ft. ❑Yes ��No '��._ �Yes iJ No �-;Unknown
in.from to ft. �Yes ��No �r]Yes ❑No �f Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE -
/ /�I
Well owner's mailing address if ditterent than property owner's address indicated above Screen from �� to 27(!J ft. Open Hole from to .____ft.
a
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris �]Fill ❑No Obstruction
Type of Obstructions(Describe�lU�(J`�C I-�� ¢ ��/1')� _____
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM 70 Obstructions removed? �Yes []No Describe E
FORMATION
PUMP
' If not known,indicate estimated formation log from nearby well or boring. �Ce n � �
_�. � ;r,j TYPe�v M- _ �.,
; ! �.9� „lr.� . :.
-- Removed ����.Not Present ❑Other_ .�
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
��.No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ',J Casing Perforation/Removal
_in.from to ft �_]Perforated ❑Removed
�� _in.from _to ft. ❑Perforated [_)Removed 4
Type of Perforator
❑Other_ _
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�' Grouting Material�/`�/ �J1*�...I�� trom U' to��R____ yards�.� bags
i
- � _ from to ft. yards bags
� from to ft. yards bags
OTHER WELLS AND BORINGS
a REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? ��J Yes No How many?_
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
RECEIVEDis true to the best of my knowledge.
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- ��f� Rj � �`)O�� Licensee Busines N e License or Registration No.
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C�N� ��, � �f =J . ��
F ORONO ertilieA epresentative Signature Certilied Rep.No. Date
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I.00AL COPV � �j � ��7 __ _ 9 _�9' __-- -
Name of Person Sealin Well or 8 in
HE-01434-13 IC#140-0423 � 5/72R