HomeMy WebLinkAboutwell info _L OH BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' ��O�'1 Q�
uunry Name
WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. `J V
Henciepin Minnesota 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
Octimo 117 23 7 4 1,25 ;, , _
c
GPS Latitude degrees minutes seconds � Q �
LOCATION: Depth Before Sealing 4� ft. Original Depth !� ft.
Longitude degrees minutes seconds qpU1FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer
2256 Shadywood Rd, �rano 55391 WELL/BORING �ileasured ❑Estimated
�Water Supply Well ❑Monit.Well �
Show exact location of well or boring Sketch map of well c� g �( /�
in section grid with"X" � location,s �' ❑Env.Bore Hole ❑Other v ft. �elow ❑above land surface
N � lines,roa ,and buildin s. CASING TYPE(S)
r � izSteel ❑Plastic ❑Tile ❑Other
T�
W --�- - -- - -- -- — E � WELL.HEAD COMPLETION
� , � , � Outside: ❑Well House Inside: ❑Basement Offset
-,-- ;-- ' i-- � �
, �m��� ❑ Pitess AdaptedUnit �Nell Pit
� � � � �
-i-- -i-- -i-- --�-- 'tj �� �.
\. ❑Well Pit ❑Buried
S / r
�i mde—� t..
❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� Diameter Depth ! Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it different than well bcation address indicated above �� �j�f
� in.ffom � to�ft. ❑Yes [�lo ❑Yes ❑No ❑Unknown
In.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
l �
Well owner's mailing address if different than property owner's address indicated above Screen from�t0��ft. Open Hole from t0 Tt.
OBSTRUCTIONS
�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) .��/n 1/� /"��!-^_ ¢ ,f� �
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ES ❑ NO D@SC�ib2 '
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP -�^ ,/�
� Type U f T ( U M n
�' � � �llRemoved ❑ Not Present ❑ Other
7�.
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�o 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.)
A fa�f17`�c^L�?'I/.f�t�'T Q� r
Grouting Malerizl /� �to_�tf2 ft. yards � bags
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 No How many? -
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapier 4725.The information contained in this report is
true to the best of my knowledge.
Don Stodola Well Drilling Co,, Inc. 27172
Contractor Business lame --- License or Registration No.
� �( G..�
A ri e resentative-Signature Date
���:. , ���.��,Q,�tY��
LOCAL COPY H 210 0 8 6 Name ol Person Sealing Well or e ing