HomeMy WebLinkAboutWell and Boring Sealing Record MAR-22-2011 11 : 12 AM LEUTHNER WELL INC 952 443 2582 P. 02
• Minnesota Well end Boring : • , .ilIl
MINNESOTA DEPARTMENT OF HEALTH Sealing No.
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MIW ve nmea No ue Well No,
Cou•y'ems 4. Minnesota Statutes,Chaplet 1091 F.urrcw+rh
i/ // Dew Well or Boring Construct �.
�.. ., Det•seel.d,.► /G 0 -
rnshlp Name r nrhip'o Range No. Bectl_on No, F .b on(fir 3ig.) 'I /
' 4 JI. Original Depth
Latitude —_.__ degrees___ minulee—— seconds Depth before Beeung—
LPB minut.e-- seconds STATIC WATER LEVEL
LOCATION: Longltud..___._ depn•e AOUI�ER(9) ,
01 Single Aquifer ❑Munlequller r` Estimated Dab Measurod.�
Meaeuroe ❑ •
Numerical Street Address or Fire Number and Cl ..1 II or c ring Lobe m yyeLLJOGRING •
J - I :d Water-Supply Well ❑Monk.Well above land surface"� Other -n, ❑below L� _
Sketch map of Well or boring ❑Env gore Hole ❑
i n exact to anon•/ Ir •drinq location,snowing prop
in section grid with" r I ee,roads,and b CASING TYPE(e)
N
1..,.._t__. 9 .r.Steel ❑Plastic C]Tile ❑Otner----
1 ) • WELLHEAD COMPLETION
i_"'_i__.••i , ❑AI Oreae Indd.: ❑Baaement Offset
W E Outelds: []Well House
I
•
❑Burted Ca Well Plt
I ! ;--' TIM* Asides Adapter/unit ❑Burled!
--.4.----1----Ir---14--- I41( ❑WII Pk ❑Other
e 1 ❑Other_
Nrilli ..
R'S NAM. • •- NV NAME CASIDiem (o) Ini aiL4'�
I:
PRO:•!�- p. Set In oversize hole? Ahnuler apace •'r n',I'1
,J � _ ✓� r. DlemylSr L
Pro :.I'ti•ddrae.' d'�. '�en •.I I a,en eddnu lndlo•ud ebov •
td II. ❑VN ❑No [:Yes ❑No ❑ ..;.,•.•,. ,
641)P411411'
�� n. ❑Yee ❑No ❑Yea ❑No ❑LMi :';
In,Irom�— to �• • 1I'i
J�� _. in,from______
ft. ❑Yee ❑No ❑Yea ❑tee Q UNgiown
ili
SCREEN/OPEN HOLE , ,I;!.,•;:•;I
WELLOWNER'9 NAME/COMPANY NAME !i' •;•'"•IiI li
e�'� to _.3n. Open Hole from to l:•lug,l • '
Screen Irom u''
Well owner's mailing address II 4ki•nrrt than property 4"rn•r's edema IndlceleC above ((/(�wv.,��l[ - •• •'I :11;14;11I
OOSTWUCTIONS •' ` ..:i1;.:,•!,!1:;
, '
❑Rods/Orop Roo ❑Cheok Valve(s) [2Debrle ❑Fill ❑No Obstruction I;,i,.
Type of Obstructions(Deecrlbe) q,l;,;iii;,i
GEOLOGICAL MATCRI4COLOR rt1RDNlA90R FROM TO Obstructions removed? ❑Yee ❑No Describe_ I
li
i I'li,.;i
FOANATION PUMP •
If not known,Indiceh estimated formation l0•from nearby well or boring. ;'• I;i :li;i
TyDe_ � ':ih , 'it rl'�:,:I
7 Removed ❑Not Present ❑Other , •
' `, McTMOD USED TO SIAL ANNULAR SPACE IITWEbN a CASINOS,OR CASINO AND Wit HOLE: II luuil.II^ill'
❑Na Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Gaeing PeROral I;i•liit.
• ❑Perforated ❑
•
In,from to II. .'Il • :,,!:;ai:
• in.from to n. ❑Perforated : ❑Removed
•
1" Type of Perforator • . • "I Ih'
• j,;j;lli l
,I
GROUTING MATERIAL(9) (On.big of cement•55 lbs..one beg of bentonite•50 lbw.) l,
,,;1,11;1 ill I ith
I,
Grouting Material L viol ,;l•;•i Illi
T I:•..
ri MI!'
from to n. yards b!p!„
from to ft
...Li• .I,, •.li u
OTHER waLLli AND BORINGS • :('I'::' II 1':
REMARMSOURCE OF DATA,DIF�ICULTICS IN SEALING Other unsealed and unused well or boring on property? ❑`lea No How many? I''i.wi i I!;
I LICENSED OR REGISTERED CONTRACTOR CEIrTIPICATION • I' ,0 u:R'i
Thla well or boring wee sealed In accordance with Minnesota Flutes,Chapter 4725 The IMdrmatlon c ndai lad Ii1.1S+1i;46el
Is Inks to tn..•et of my kn•, Op. ;. •ill I'
r.: , .1.,.. _ i
L -: ..sires.Nems Lk•as of' trefloA I O.
! /l �, ` ie fl
ff✓��_i ; i�- _/'� ., lii',.. i,.
LOCAL COPY H 284447 :r -� .,or_o,,�.
'l 1 WIis.