HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota
Well and Boring H 103501
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank if not known)
Township N e Township No. Range No. Section No. Fraction(sm.->Ig.) Date Sealed Date Well or Boring Constructed
y "
Numerical Street Address or Fire Number and City of Well or Boring Location -
r Depth Before Sealing —ft. Original Depth ft.
Show exact loca I n of Mor boring I Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X' -• location, showing propertyIngle Aquifer E] Multiaquifer
lines,roads,and buildings. -
N WELUBORING ❑ Measured �stimated
Vater Supply Well ❑Monit.Well /
---- --^ ❑ Env.Bore Hole ❑Other ft. P11(elow ❑ above land surface
W --r- -�-- --�-- --�-- E ,�. �1J/ CASING TYPE(S)
- -- -=-- --=-- --=-- „ feel ❑ Plastic ❑Tile ❑Other
Ya mile
CASING
Diameter Depth f Set in oversize hole? Annualar space initially grouted?
pfr r mneie - _ "'"'• _ in.from_S�� to ft.
E]Yes o E] Yes E] No El Unknown
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown
Property owner's mailing a dress if different than well oca ion ad ress indicated above. in.from to ft. ❑ Yes ❑ No ❑Yes ❑ No ❑ Unknown
6033 Cherrywo d Lam, SCREEN/OPEN HOLE /
Mound s NN 5536+ r t Screen from�to � ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME 1*Obstruction ❑ Debris ❑ Fill ❑ No Obstruction ..�•
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill 9""
Obstruction/Debris/Fill removed? Xes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed of Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
tlo Annular Space Exits
`❑`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 j/t r- to ft. yards t' 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 :k-
LICENSED OR REGISTERED CONTRACTOR CERTIPfCATibN
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.
Q {"
Contractor usiness ame License or gt r No.
q o d epresenta b Signature Date
r
i� 5 0 Name of Person Sealing Well or Boring
LOCAL COPY H 103
HE-01434-02 10/95R