HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring /�/� ��
County Name - WELL AND BORING SEALING RECORD MinnSealesota
to H LJ 4J
Minnesota Unique No.
HENNEP 1 N Minnesota Statutes,Chapter 1031 or W-series No. 2
966
(Leave blank if not known)
ak6one Township No, Range No. Section No. Fraction ism.-,,Ig.) Date Sealed Date Well or Boring Constructed
119 23 8 E XW ME, NOV 03, 1997 09-28--96
Numerical Street Address or Fire Number and City of Well or Boring Location
980 TONKAWA RD Depth Before Sealing 135 ft Original Depth ? ft
Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X- location, showing propertySingle Aquifer ElMultiaquifer
lines,roads,and buildings.
N WELUBORING Measured ❑ Estimated
I Water Supply Well ❑Mont.Well
-
I Nt e,4� ❑ Env Bore Hole ❑Other 60 ft. below Elabove land surface
W --r•-----------------------E - CASING TYPE(S)
- -- - -- -i-- -- Steel ❑ Plastic ❑Tile ❑Other
—le
1
r. t
CASING
1 Pi{ S yy Diameter Depth Set in oversize hole? Annualar space initially grouted?
LlS """�J�""" Y 4 0 130 fvl Yes No Unknown
1 mile `"' in.from to ft. ❑ Yes `fes No ❑ ❑ ❑
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
TOM POTTER CONSTRUCTION INC;
Property owner's mailing address if different than well location address indicated abovein,from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
165-31 DEVONSHIRE DR SCREEN/OPEN HOLE
HMHAS SEN, MN 55317 Screen tram 130 to 135 ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill 14 No Obstruction
SAME
Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe)
Obstructions removed? ❑Yes ❑ No Describe
PUMP
Type �}fi
RE Cali
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ,6 Removed ❑ Not Present [I Other
FORMATION
It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CAS�uuMDQO
'LAY YELL Q 2C) dr FWV-1
r No Annular Space Exits YY LL q�'
ED Annular space grouted with tremie pipe �^ v�:URONO
SAND GRAY ARG 60 ❑ Casing Perforation/Removal vlY
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
BENTONITE 135 SURF '•
Grouting Material from 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 OTHER WELLS AND BORINGS
GEOLOGY FROM: UNIQUE #562966 Other unsealed and unused well or boring on property? ❑Yes P!rNo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
WATER LEVET. IN ABOVE WELL: 60
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
DATE WATER LEVEL TA KEN: 09-28-96 true to the best of my knowledge.
"-157
E.H. RENNER & SONS, INC, 7.1015
Contractor Business Name License or Registration No.
11/5/97
�r `r Authorized Re sentative Signature Date
-,cording to MN Ctate Rcr►olatir Ii� KEVIN SCHEITERLEIN/RAY RENNER
LOCAL COPY 7H
129771 Name of Person Sealing Well or Boring
HE-01434-03 2/97 R