HomeMy WebLinkAboutwell info WELL OR BORING�OCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota I q, `� `� � S `�' �
Sealing No����� L,� ' J �r !`
` County Name WELL AND BORING SEALING RECORD Minnesota nique Well No. �—
Minnesota Statutes,Cha ter 1031 or W-series No
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Township Nam`e Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Wel �n o strtic ed �
1 '�` �'�`' 'r � 1.�
� GPS LOCATION-decimal degrees(to four decimal places) � c� �
:� � Depth Before Sealing_�_�___ ft. Original Dep[h_ ___________ ft. �
Latitude__ _ _ Longitude
�UIFER(S) STATIC WATER LEVEL
Numerical Sireet Address or Fire Number and City of Well or Boring Location , ingle Aquifer �_'��Multiaquiter V
c+f WELUBORING Measured � �Estimated Date Measured�� �! __
`�� ?�i� :I.la�.!� Q� �� �CnC�C) �- ater-Supply Well ��Monit.Well j — ��-
Show exact location of well or boring Sketch map ot well or boring - - �� below �' �
in section grid wdh"X:' location,showing property �Env.Bore Hole ', :Other__ _ �.� ..__ft. � above land surface
N lines..roads,and buildings. CASINGTYPE(S)
:. -'--- - --` - -'-- �
;; j j j Steel ���._'��Plastic � Tile !,�Other
� --'-----�-- ---`- --`-- WELLHEAD COMPLETION
� ,�, ; : �, : ET .
; ; ; _ �____;__ Outside: 'J�Well House . I,At Grade Inside� '�Basement Offset ,�
���Mi1e ❑Pitless Adapter/Unit - .Buried � I Well Pit
--,--- --.-- --.- > - 1
Buried
' S ' �:_'-WeII Pit
�,]Other
�-1 Mile--� _.Other__. __ _ __,_.__
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �
Ca ' Diameter � Depth � Set in oversize hole? Annular space initially grouted? .
Property owner's mailing address it ditterent than ell location address indicated above �r�in.Gom� to_��ft. !_j Yes �No [_Yes ❑No i J Unknown
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125 ���n �t ���`f ��� ��� in from to fL � �Yes I �No L Yes ❑No _�Unknown
"'innea�lis, '��`� 55414
in.from ta ft. �Yes �. '�No '_�Yes ❑No L��Unknown
WELL OWNERS NAME,'COMPANY NAME SCREEWOPEN HOLE
Well owner's mailing address it different than property owners atldress indicated above SCreen irom_� ! _to_���_ft. Open Hole from ____, ,.,_to ft. ��
OBSTRUCTIONS
� Rods/Drop Plpe '�.i Check Valve(s) �I Debris �1.Fill [..j No Obstruction
�� Type of Obstructions(Describe)_��l�jf��' _��_��_ ¢_�.� ��
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7 ��Yes ',_I No Describe_
FORMATION
PUMP
` If not known,indicate estimated formation log from nearby well or boring.
.. TYPe-- � {-j��. �r . �
-- -�----------
� Rema� .-�.;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 �. ''�,Casing Perforation/Removal
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in.from to ft �. ��Perforated [ �Removed
�. in.from to. . ..ft. i..!Pertorated , :Removed >
. `.
Tyoe of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ,Yes �_�'�.No TN# ��
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
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Grouting Material���a�y�����rom� to2_��_ ft,_,______ yards_�.____ bags
; from_.__ to_ fl.___. ._ yards _ bags �
r __ irom__ _ . to_ _. ft._.___.. ___ yards ___ bags
OTHER WELLS AND BORINGS
�� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? _Yes o How many?_ ��
, - __.___ ---. . ..�.
t� • �.;�., LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in acwrdance with Minnesota Rules.Chapter 4725.The information contained in this report
� ��'���-`�""��'�---�^— � �,��, is true to the best af my knawledge. .
�on St�x.?oIa t'ell '�rillic� Co,.Inc. I���'1 "
--- -- --_ ----- - _ - - __
Licensee Business Name � License or Registration No.
.. � '�^.�'. , .
� � - 1?,-2 3-15
-;-;, —_t�����
. -- -- _---- _ _ _.
.CePr e ese`ntative Signature Certilied Rep.No. Date
H Ji� Antonson
LOCAL COPY 3 3 5 4 2 7 _ _ -- - -- - _ _ _-- _-- - -- �
Name of Person Sealing Well or Boring
HE-01434-14 IC#140-0423 5'�3R