HomeMy WebLinkAboutwell info� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �O Q���
County Name WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. `�Q `
Minnesota Statutes,Chapter 1031 or W-series No.
(leave blank i not kn wn)
, Towns ip am Township No. Range No. Seciion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Oraio 127 23 I7 N� N9� S� 22 J�1N 14
,
GPS Latitude degrees minutes seconds Depth Before Sealing ��� ft. Original Depth ft.
LOCATION: Longitude degrees minutes seconds AQUIFER(S) STA71C WATER LEVEL
Numerical SVeet Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer /�Qy/
�W L/BORING �i Measured ❑Estimated Date Measured�� IJ(71
Water-Supply Well ❑Monit.Well �
Show exact location of well or boring Sketch map of well or boring
in section grid with"X." location,showing property � i Env.Bore Hole ❑Other l�_ft. �below ❑above land surface z
N `� lines,roads,and buildings. CASING TYPE(S) z
° --'-----i-- ---`-----'—
�
,\ �Steel ❑Plastic ❑Tile ❑Other
�% I I I I � `l'
-- --------- --- ----- -- WELLHEAD COMPLETION
W ; ; ; ; ET
' � I _;_ ___;__ � � , utside: ❑Well House rl.At Grade Inside: ❑Basement Offset
��. O � �
. ------------ -
� � � � � 'h Miie � ss A p r/Un t �)Buried ❑Well Pit
.,,
� , , � � �
, , , , �P'itle da te i
��i --;----T-- ---�—---:-- I_.-.....� ' � i�Buried ;:.
' ' ' ' L � ❑Well Pit
S ]Other
�7 Mile� ❑Other
PRp�pp.E.R.TY OW�7�,E�R'S�}1,AM COMPANY NAME CASING(S)
y«� •`�+�t`+ ��• Diame r�� � Depth � Set in oversize hole? Annular space initially grouted?
� Property owner's mailing address if different ihan well location address indicated above ��n.from `✓ to�ft. ❑Yes �No ❑Yes No
� �t O a��� `� ❑ ❑Unknown
,
_ TOL'ljCS Btlj,� � n55331 in.from to ft. ❑Yes �]No []Yes n No ❑Unknown
in.trom to ft ❑Yes []No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � / Y
Well owner's mailing address if different than pioperty owner's address indicated above Screen from �� to�g� fl. Open Hole from to ft.
OBSTRUCTIONS
[Rods/Drop Pipe ❑Check Valve(s) []Debris ❑Fill ❑No Obstruction
� Type of Obstructions(Describe) p.l���_ _,�/'LJ�a(4
GEOLOGICAL MATERIAL COLOR NARDNESS OR FROM TO Obstructions removed? es �1 No Describe
FORMATION
PUMP �
If not known,indicate estimated formation log from nearby well or boring.
Type
��� �"- �� � f ��� ❑Removed �Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. [Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator ___
��']Other -
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
, � -
_ Grouting Material�i��/���� from_�_ to�_�8 ft. yards !/� bags
r y
from to ft. yards bags
from 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?
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.
Don Stod�la Well_Drilling Co,, Inc. 2691 '
Licensee Business Name � 1 License or Registration No.
1��.—�---...� �•.
f .�/ /��� i�e'�� 'a'�.r} � _4
rtifie epresentative Signature Certilied Rep.No. Date
. •..�, -. y �..,, �n`i a 4.fi_�t y�.J
LOCAI �:O?Y H 2 8 8 9 5 6 Name of Person Sealing Well or Boring
HE-07434-12 IC#140-0423 �.� siosa