Laserfiche WebLink
, ,�. <br /> :- r :� <br /> MINNESOTA DEPARTMENT OF HEALTH M�nnesota Well and Bormg � �4 6�7�� <br /> ������� WELL AND BORING SEALING RECORD Sea�ing No H <br /> �ry�^� Mmnesota Urnque No. — -- � <br /> Hennepin Minnesota Statutes,Chapfer 1031 or W-series rvo. <br /> ILeave b�ank il n��known) <br /> Townsftip Name Townshlp No. Range No. Section No. Fraction�sm.-s Ig.) Date Sealed Date Well or Boring Constructea <br /> arano 117 23 OS LZ-a02� � p{/ ^ <br /> Nurtiencal Stree1 Address a Fire Number and Ciry o(Well o�Boring LocaGon � ! <br /> 60 S a7t�Ib� �8� L�,d y 4rons S 5359 Depth Before Sealing �� H O��ginal Depth ���> 8 <br /> Sbow e�cact location ot`rell a boring Sketch mae of well or bormg qpUIFER(S) . STATIC WATER LEVEL <br /> n section grid wNh'X'. locatio�owing property ��Single Aywfer � Multiaquifer <br /> lines, an�ab itdin �[ <br /> N � rZ� �� � WELUBORING �LI Measured ❑ Estimated <br /> S:,v <br /> 1��j Water Suppiy Well ❑Monit.Well �r� � <br /> ` �^�--� ^ 1 ❑ Env.Bore Hole ❑Olher _ _w� R. �below ❑above Wnd wAace <br /> W 'Y- 'Y- 'T- -T- E '� CASING TVPE(S) <br /> -ir- -r- -�-- -�- ��, :.$ Steel ❑ Plas6c �Tile � Other �� <br /> um�.: -...___�.._ <br /> -�- -�- -i-- -j-- � - CASING <br /> 1 Diameter Depth � Set in oversize hole? Arwwalar space inhially grouted? <br /> S J� - /fi �4 <br /> �t mis� . �_ in.from ✓ to �� ft. ❑ Yes �No ❑Yes ❑No ❑Unknown <br /> � r. <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Y�s ❑No ❑ �^k^oN'^ � <br /> � <br /> Prape�ry owr�s maiy address if dilferem than well locaaon a ress indiwted above. in.from to fl. ❑ Yes ❑No ❑res ❑No ❑Unknown <br /> � SCREEWOPEN HOLE <br /> Screen from�to "=��j � ft Open Hole from to k. <br /> OBSTRUCTIONS <br /> �LL�����"� Rods/Oro Pi <br /> ❑ p pe ❑ Check Valve(s) �'Debris ❑ Fill ❑ No Obstrudion <br /> WM ow�efs m�ip addrees N dilhrent Man properry ownefs aCtlress indicated above. Type ot Obstructions(Describe) �\;�4�:,��T�' <br /> Obstructionsremoved? �Yes ❑ No Describe <br /> PUMP <br /> 7ype <br /> (�EOLOQICAL YATEitlAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> q�b�������������o��� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> , No Annular Space Exits <br /> r: � -. <br /> ` <br /> ❑ Annula�space grouted with tremie pipe <br /> �.� ❑ Casing PeAoration/Removal <br /> in.from to fl. ❑ Peibrated ❑ Hemwed <br /> in.from ro R. ❑ Perloralsd ❑ Rertwved <br /> Type of perforator <br /> ❑ Omer <br /> GROUTING MATERIAL(S) <br /> Ai,�s'.`�'�;;��M,�'r��— �� � <br /> Grouting Material om to ft. yards�,,,,_ bags <br /> trom to fl. yards bags <br /> from to ft. yards bags <br /> from to__ fL yaids begs <br /> REYARI(8,SqIRCE OF DATA,DIFFICULTES IN SEALING OTHER WELLS AND BORINGS <br /> C�ther unsealed and unused well or boring on property? ❑Yes�No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring wes sealed in accordance with Minnesota Rules,Chapter 4725. The iriortna�qn oaRained'n tfrs report is <br /> true to the best of my knowledge. <br /> Don Stodola t�ell D C I <br /> Confredor Business Name � ; i L.iosw w Reps6atlm 170. <br /> --� . � ' .��3 <br /> .: .�� , � � �� � �,�.r <br /> �,i 3 1��.� - _ <br /> uth ed epresentative Signatuie Or�s <br /> t z �• <br /> . . .. . . . ..... ... •/" ..J" 4\1�����,..�.�iV'�'.... <br /> H ���^� ` Name ol Person t ling Well or Bonng <br /> LOCAL COPY �� * <br /> i <br /> HE-01�.3�00 ?J97 R <br />