HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring I H �� e ��I� —�
Counry Name WELL AND BORING SEALING RECORD Sealing No. � r} C
Minnesota Unique Well No.
'#�������� M�nnesota Statu�es,Chapte�]031 or W-series No. I
(Leeva HaMc 11 not known) �--_"__— J
Townshlp Name Township No. Range No Section No. Frachon�sm.i Ig.) Date Sealed Date Well or Boring Constructec]
f?X O Il0 Z�.� Z� �� Z�S—`�C�� C" ,;�,� - ,....
Num(e�rical Sireet yA,ddress or Fire Number Ta�nd City ol/W�ell or Bonng Location ^� �
1J��> �lt.c`�C��C�oQ� iid� VrQn� 553�1 DepthBeforeSeahng �?G { R OriginalDepth � /4. ft
Show exact bcation of well or boring Sketch map ol well or bonng OUIFER(S) STATIC WATER LEVEL
m section grid wlth"X". ,\ location, showing propeny � Single Ayuder ❑ Multiaquder
� lines,�oads,and buildings. ]/
N ':y} WELVBORING ILrMeasured ❑ Eshmated
� � � � � �';�^ � �Wa1er Suppry Well ❑Monit.Well .
-�- -�-- —;-- — . �
-- ,t�� � �
. � ❑ Env.Bore Hole ❑Other _�ft. (�pelow ❑ above land surtace
W —i-- -i-- -i-- --i— E _ CASING TYPE(S)
� � � .,, �_._.�._�.
� � � ` .� 4
� � � �/
-�— -�- -�-- --�- � �.•� � I ySteel ❑ Plastic �Tile � Other
}�mile { �r
' -�-- -�-- -�-- --�— • t CASING(S)
S ' ��y.�� M Z\; Diamete�� Depth ( Set in oversize hole7 Annular spaCe initially grouted?
\ va. L//
�i mire� -J�i �'✓� % �.� � in.from� to��. ❑ Yes �o ❑ �es ❑No ❑ Unknown
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
- Properry owner's mailing address if diMerem than weil iocanon address�ndicated above. in.from to R. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
?(�A �i' La�� f�.'L SCREEWOPEN HOLE
�d�t f �
t��yzat a, t"dkY 5 5�9 I Screen trom��_to�.� tt Open Hole from to tt.
�.L Ctl:�E'LQCI'S Tessier oesraucnoNs
WELL OWNER'S NAME w + (�/Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction/'�
Well owner's mailing address it diflerent than property owner's address indicatetl above. T p of Obs�ruClions(DeSClibe) �/�/L-'�l��. �� �� e' U//// )
Obstructions removed? [�es ❑ No Describe
PUMP
TYPe�G�UJ,+S ��/l�lf
6EOL0(i1CAL MATERIAL COLOR HARDNESS OF FHOM Tp �Removed ❑ Not Present ❑ Other
FORMATION
N not krwwn,intlicate estimated formation log from nearby well or ponnq. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
. ,s�o Annular Space 6cists
� ") ' ����
�Annular space grouted with tremie pipe
❑Casing Perforation/Removal
r
in.from to k. ❑ Pertorated ❑ Removed
in.irom to ft. ❑ PeAorated ❑ Removed
Type ot pertorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
i
Grouting Material 1�✓''�� � �5"' -`��146�� to�R. yards � bags
irom to ft. yards bags
irom to ft. yerds bags
from to__ ft. yards bags
qEMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes o 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 is
true to the best of my knowledge.
�?c���z '::�to�3o�.� rt�7ell Drilli.n > �o. Irac. 27I7�
Contracror Business me - �� License or Registration I'ro.
,�� tF�'�rr�l���' ��T� ��i .:�C,`
•l.� �. .g �
AifironzbARepiesenfative Signature � Defe
1
� � . . ,'i;'' ' ;..,_ ._...v
H �+ �� l � Name o!Person Sealir�tj,Well or Bonng
LOCAL COPY a �