HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ��+.q +��rt �
WELL OR BORING LOCATION Sealmg No. I�"� ,��� g C
Counry Name WELL AND BORING SEALING RECORD M,��eso,a��,q�e No —
��p Minnesota Sfatutes,Chapter 1031 or W-series No. �
\. N~ ILeave blank if nol known) --
Township Name Township No. Range No. Section No. FracGon(sm.->Ig.) Date Sealed Date Welt or Bonng ConsVuctetl
a�
C.�✓'_ h�.> r r.
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Numencal SVeet Atldress or Fire Number and Gry of Well or Bonng Locahon �
� 7 � � Z
1�_', /�L,� ._ � �,.����� ��u� �L J Depth Before Sealing � ���- M. Original Depth M
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Show exact loca6on of w•ell or bonng Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL
in section grid wrth"X'. location, showing property �Single Aywfer ❑ Multiaquiter
- lines,roads,and bwldings.
N ,,,� WELUBORING �Measured ❑ Esumated
� � N�' �waier Suppiy Weu ❑Monit Well
-�-- - - -;-- - � �,/
; ; ; --} , ❑ Ern.Bore Hole ❑Other _ 0./"� R. L•y below ❑ above land surface
� �y��
w --�- - — -i-- --i-- E ,� � V''� CASING TVPE�S) .
y � � � � �
r � � � �
; —�- -�- -;-- --�-- � ,_ �Steel ❑ Plastic ❑Tile ❑Other
� u mde � �
� � � � ,, CASING
—�- -�-- -�— --�-
� --S � Diameter Depth Set in oversize hole? Annualar space iNtially grouted?
S �,� .._-..-_. � ` �
��m�� in.irom � to °�� �� R. ❑ Yes �No ❑ Yes ❑No � Unknown
� PROPERTY OWNER'S NAME � in.from to fl. ❑ �es ❑No ❑ �es ❑No ❑ Unknown
I�J: 1 i} I � - �
Properry owner's mailirg address If diRerent than well IocaUon address mdicated above. in.trom to ft. ❑ Yes ❑ No ❑�Yes ❑No ❑ Unknown
=; ir-�,y"L. SCREEWOPEN MOLE
Screen from to k. Open Hole from to k.
OBSTRUCTIONS
WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill � No Obstruction
Well owner's mailing eddress if different than propeTj owner's address mdicated above. Type ot Obstructions(Describe) �" �-��
Obstruclions removed? �Yes ❑ No Describe �" L''��
PUMP
Type
GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Q� Not Present ❑ Other
FORMATION
If not known,irWicete estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� No Annular Space Exists
iv/ry ❑Annular space grouted with tremie pipe
� ❑ Casing Perforation/Removal
in.from to ft. ❑ PeAorated ❑ Removed
in.from to ft. ❑ Pertorated ❑ Removed
Type of pertorator
❑ Other
GROUTING MATERIAL(S)
1 �
�' ,. S /
Grouting Matenal � ' � 1'� �' i E from � to �+� ft. yards / begs
trom to tt. yards bags
from to ft. yards bags
from to-- R. yards bags
REYARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Olher unsealed and unused well or boring on property? ❑Yes �No How many?
��� �,. � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
\;.... � , b.=
� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information conteined in this report is
- true ro the best of my knowledge.
E,�j;.. �,:, . �`,1,a 1 � ,7; `� `7
Confrador Business Name License a RegishaGon l'vo.
' I �.,,�,-._ ( - J j ` S`I
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Authonzed Representefive SigneNre Dare
..'1 � � �,JR � �. - 1 55
1'
H � Name ol Person Seeling Well oi Bonng
L�i/V. '��
HE-01434-04 8�98 R