HomeMy WebLinkAboutwell info Minnesota Well and Boring ^ ^
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H L 8
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
Minnesota Statutes.Chapter 1031 or W-series No.
(Leave blank it not known)
Township Name ownship No. Range No. Section No. Fraction ism. Ig.) Date Sealed Approximate Date Well
I ' --j '2 - IQ (l4 4 ' , - :� '-71 or Boring Constructed
Numerical Street Address or Fire Number and City of Well or Boring Location
Depth Before Sealing 1 ft. Original Depth i` `I�� ft.
Show exact location of well or boring Sketch map of well or boring Static Water Level 57,Accurate
in section grid with"X. location,showing property lines.
N roads,and buildings. ElApproximate
single Aquifer ❑Multiaquifer --�ft. below above land surface
t i i t
-t- - - -i- -t- CASING TYPE
W E
t t t t
t t t t Steel ❑Plastic ❑Tile ❑Other
Ll
mile
S Screen from I{>L.. to ft. Open Hole from 10 ft.
1 mile ► OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME Obstruction ❑Debris ElFill
Type of debris/obstructionL1.*
Mailing Address if different than propill address indicated above.
Obstruction/Debris/Fill removed? Yes ❑No
PUMP
EkRemoved ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring.
�
infrom to ❑
c
l\ . �J.IL"ft. Yes Elo ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
XNo Annular Space Exists
❑Annular space grouted with trial pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
Grouting material I i \ - .r. from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
/�
((�� Other unsealed well or boring on property? El Yes Q(No
NOV V
V 3 1.393 LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
E , U_ _ l l l l
4
Contractor Business Name License or Registration No.
r y ' C.
Authorized Representative Signature p Date /
LOCAL COPY H 4 V V 2 V \
Name o/Person Sealing Well or
Boring
HE-01434-01