HomeMy WebLinkAboutwell info wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 2 5 6 3
County Name
WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique No.
Minnesofa Statutes,Chapter 1031 or W-series No.
� (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
t� i i i _ �; _ � / �,� �r, ,
Numerical Street Address or Fire Number and City of Well or Boring L.ocation
� Depth Before Sealing ��� " ft. Original Depth � !! � ft.
6 i. � _
Show exact location of well or boring Sketch ,ap of well or boring ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property �ingle Aquifer ❑ Multiaquifer
lines,roads,and buildings.
N i WELUBORING �'Measured ❑ Estimated
� � � ....,- {�Water Supply Well ❑Monit.Well
� � „� ) [/�/
r_ _�' "�_' '_�'_ ' ..._. '. 1..r VO 2f1 � • �� � ..
-��"`- ❑ Env.Bore Hole ❑Other ft. �below ❑ I d s rfac ..._ _��.
W -�- -�-- -i-- --i-- E '; �� CASING TYPE(S) .
� � x �
, : _
I I I - � 1 ,n�. �
--�- -�-' --1-- --�- ' L.J� [�Steel ❑ Plastic ❑Tile ❑ Other
� 'b mile,.,
--�- -�-- � ;' � CASING
--�-- ---{--
-s � Diameter Depth Set in oversize hole? Annualar space initially grouted?
LL"" S """��1��� � � , � �
p�t mi�e-�n � in.from �,,:� to J�L� ft. ❑Yes �Jo ❑Yes ❑No [�,�LJnknown
I I
PROPERTY OWNER'S NAME ;\ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
r �" :
Property owner's rPf iling address i different than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEN/OPEN HOLE
� �-r ;�-�', Screen from ro ft. Open Hole from ro ft.
O B STR U CTI O N/D E B R I S/FI L L
WELL OWNER'S NAME � IA Obstruction Debris
:.J� � ❑ ❑ Fill ❑ No Obstruction
: y... �
Well owner's mailing address if diHerent than property owner's address indicated above. Type of Obstruction/Debris/Fill f,J�' j�� ' a�' ��(� ��- �-
�-,�-
Obstruction/Debris/Fill removed? � Yes ❑ No
PUMP i
Type � _ Y
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�..No Annular Space Exits
r t�
. ❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to tt. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
� 4' ,
Grouting Material �-, ��� from (� to�a 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 BORINGS
Other unsealed well or boring on property? ❑ Yes �,[Jo
�.,,y ; , LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
�.J�.. '� . � � . .
� � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
[rue to the best of my knowledge.
1 � ' r j'' ii � ,� -� � : t !
Contracfor Business Name License or Registration No.
f .... � ;: _,��� -r,.- �-r i
Authorized Representative Signature �'-' Date
� � � r
r: r-4 n Name of Person Sealing WeH�r Bonhg ��+� � �
LOCAL COPY H i � �'` �"; �j �
HE-Ot 434-02 10/95R