HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 6 7 2 3
WELL OR BORING LOCATION Sealing N0.
CountyName WELL AND BORING SEALING RECORD
Minnesota Unique No.
�rr� Minnesota Statutes,Chapter 1031 or W-series No.
Ax=%��p� (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed .
� �27 L»J ZV ��i��t '/a i!
Numerical Street Address or Fire Number and City of Well or Boring L.ocation �
/ /-�
2�77 ,�,)�d�I�Q� �� �c�r� 5�3� Depth Before Sealing ft. Original Depth �./ ft.
Show exact location of well or boring Sketch map of well�r boring ApUIFER(S) STATIC WATER LEVEL
in section grid with"X". , location, showing roperty ingle Aquifer ❑ Multiaquifer
�� lines,roads,and bu d� s. ,�/
N ,��, �1 ELUBORING �easured ❑ Estimated
� � � � �/dJater Supply Well ❑Monit.Well ��
--�- -i-- --i-- --�-- � �„�,,,. . /\• . .
}} ❑ Env.Bore Hole ❑Other ft. elow ❑above land surface
1
�y --�- -;-- --�-- --�-- E _ ;: CASING TYPE(S)
� � � �
� � � � ;
--�- -�-- --�-- --�-- � � ' Steel ❑ Plastic ❑Tile ❑ Other
1 I � I '/.mile '�
-�-- --�-- --�-- --�-- � � 't1 CASING
`�� Diameter Depth Set in oversize hole? Annualar space initially grouted?
�1 mile� �-`�� j� _� in.from.�_ to�ft. ❑Yes � �qp ❑ Yes ❑ No ❑ Unknown _
� 7 '
PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
x
Properry owner's mailing atldress if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
�Y V�S Drexe 1 A Y� SCREEWOPEN HOLE
Edina MPi 55424 ' -l�'b '
/ Screen from�to ft. Open Hole from to ft.
O B ST R U CT I O N/D E B R I S/F I L L
WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than properry owner's address indicatad above. Type of ObstruCtion/Debris/Fill ��,(�A1���1�� Q- ��� �
Obstruction/Debris/Fill removed? es ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ot Present ❑ Other
FORMATION
If not known,indicate estimated formation log irom nearby we�i or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE FIOLE:
. No Annular Space Exits
� � �
Annular space grouted with tremie pipe
:`�
;� ❑ Casing Perforation/Removal
in:from_ to h. ❑ Pertorated ❑ Removed
in.from to h, ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) �
4 '"'� f �
Grouting Material �� to��}ft. yards bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes o
LICENSED OR REGISTERED CONTRACTOR CERTIF A N
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.
o •! • License or Re � .
� _..�_.._ ' � -..
. � _ -��r �\ �/l� � �
i eseh ive Signaturef- Date `
_....!' ;
I:.,. "'�
_.i - - - -2�.s����..� �'v
n ry � � Name of Person�Sealing Well or Boring
LOCAL COPY H .E.. :.s � F � �
HE-01434-02 10/95R