HomeMy WebLinkAboutwell info BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 9 6 6
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WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique No.
�j� Minnesota Statutes,Chapter 1031 or W-series No.
'�p+�+ (Leave blank it not known)
nip Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
cono s.I� 23 zl ?�i-�6o,,
ierical Street Address or Fire Number and City of Well or Boring Location f �
Depth Before Sealing ��„�_ft. Original Depth ��� ft.
�-
.how exact location of well or boring Sketc�map of well or boring A�UIFER(S) STATIC WATER LEVEL
n section grid with"X". location sh wing property Single Aquifer ❑ Multiaquifer
lines,ro nd buildings.
N WELUBORING Measured ❑ Estimated
� � � �� Y =� Water Supply Well ❑Monit.Well �
_Y_ _T_ __l__ � ,. /�
� � � i
����--�� ❑ Env.Bore Hole ❑Other �G.�ft. �below ❑ above land surface
� � � � / "�-(--
W -�-- -�-- --i-- --i— E �" `� '�. .
�, l ..,. CASING TYPE(S) '
� i � ��
�
� � i � � �, \\. � �.:�
--�- -�-- -�-- --�— t� v �a�; \` � Steel ❑ Plastic ❑Tile ❑Other
;4 mile •. �'�>
—�- --�-- --�-- --�-- � ��.` .3 ��, .. CASING
� Diameter Depth � Set in oversize hole? Annualar space initially grouted?
L� """��J��� /
pk--1 mile�e � �"� in.from� ro / 7f ft. ❑ Yes '�Vo ❑ Yes ❑No ❑ Unknown
� � ��
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
Property owner's mailing address it difterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEN/OPEN HOLE
� � /
Screen from��to�_ ft. Open Hale from to R.
O BSTR U CTIO N/DE B RIS/FILL
WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill ,1�/�,��{��/���/7�� ¢' �)���
Obstruction/Debris/Fill removed? Yes ❑ No
PUMP /}
TYPe—,�szeV' / lJf/ �{�
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
If not known,indirate astimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �No Annular Space Exits
�� r. r .—
- ❑ 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)
/ )
Grouting Material �! _ �— to ,���ft. yards J� bags
r �
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 CERTIFI A ON
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 Stodflla ��TE2I Ari2lin� Co�. Ir�c. 27I72
Contractor Business Name License or Registration No.
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� , ;. � ,-_ . fi `��'' �a--,� �r`J ..� '� ��rs
�hz.d�eplQ'seMabve �gnature Date '
�. _..��a��,
�y Name ol Person Sealing Well or Boring
LOCAL COPY H � 1 O � � �
HE-01434-02 10/95R