Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL H 10 2 8.6 7 <br /> County Name BORING LOCATION WELL AND BORING SEALING RECORD <br /> Sealing No. <br /> Name <br /> Minnesota Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> 161 e v (Leave blank If not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed c Date Well or Boring Constructed <br /> u u u <br /> . ..� , 6. — <br /> �i� r K Cl Ic1 t <br /> NTerical-,Streerf Address or Fire Number and City of Well or Boring Location <br /> (:() kn ) Ca("N-3 <br /> 1 k UL �, � ✓ Depth Before Sealing /X 1--( ft. Original Depth / ? <br /> L! ft. <br /> � <br /> Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property [Single Aquifer ❑Multiaquifer <br /> lines,roads,and buildings. <br /> N 0`(j h k‘ WELL/BORING Measured 0 Estimated <br /> I I ‘,��` �'� '7 Water Supply Well 0 Monit.Well <br /> ❑ nv.Bore Hole Cl Other JO Lf ft. below ❑above land surface <br /> wT `, 1 , 'E \ I CASING TYPES) <br /> I 1 - 1 I <br /> --4-1---t---1 1—T oc r`' Steel El Plastic ❑Tile ❑ A'Other 7 13 c7i� <br /> I 1 I I smile bJ,_,00 -,,t. A✓ CASING <br /> I Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S 4 ! l Yes o ❑YesNo [Unknown <br /> f mne in.from `� ,to t ft. ❑ 0 <br /> PROPERTY OWNERS NAME in.from to ft. ❑ Yes ❑No 0 Yes 0 No ❑ Unknown <br /> +< . 4 `-S k . c- -„6r�n <br /> Property own # it <br /> s mailing address if different than well location address Indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No 0 Unknown <br /> 5 SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNERS NAME 4 Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> —c-9 w1/44._ jr),Well owners mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill / l ,1)i I/`,.P h . . 'i 1 ,LAn p <br /> 1 , <br /> Obstruction/Debris/Fill removed? EcYes ❑ No <br /> PUMP <br /> Type S ,-. L. IA-, . , < . 1, II C <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed CINot Present 0 Other <br /> FORMATION <br /> 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: <br /> N - _ - �No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. 0 Perforated Cl Removed <br /> in.from to ft. 0 Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) 11 p <br /> Grouting Material p ti t k, . I(from (J to /F 4 ft. yards 7 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> IU C'w 1,.,r o, k v,CI L1 I r (,,/41, (1 <br /> Other unsealed well or boring on property? F Yes ❑ No <br /> Lk 1 <br /> f\J ` , E 4 t c LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> \\ tt true to the best off�my knowledge. <br /> Contractor Business Name License or Ft <br /> eegistration No. <br /> L/,1,.. <br /> „...0,4„.1......._ — <br /> Authorized Represenfatfi a Sgn'atfire "Date <br /> h -1( ' h •• --\- , 17 <br /> LOCAL COPY <br /> H 1 0 2 8 6 7 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />