Laserfiche WebLink
WELL OR BORING LOCATION � MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and 6bring I„I ��('��� /� <br /> Sealing No. �j i� <br /> j County Name WELL AND BORING SEAUNG RECORD Minnesota Unique Well No. � <br /> Minnesota Statutes,Cha ter 1031 or W-series No. <br /> P (Leave blank if not known) <br /> Township a e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed <br /> Orcmo i17 23 05 � �E . /7 � p <br /> /`�� , <br /> iGPS Latitude degrees minutes seconds Depth Before Sealing /"L- ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location .�Single Aquifer ❑Multiaquifer /� /� f' " <br /> WELL/BORING Measured ❑Estimated Date Measured c'I'�mF �J�7� � <br /> �/ater-Supply Well ❑Monit.Well � <br /> Show exact location of well or boring Sketch map of well or boring Env.Bore Hole ❑Other �� ft. �]below [J above land surface <br /> in section grid with"X." location,showing property r � <br /> N lines,roads,and buildings. CASING TVPE(S) - <br /> s <br /> --'-----'--- --`----'— � <br /> �Steel ��]Plastic ❑Tile '�_I Other <br /> '� --'-----'--- ---`-- ---'-- ELLHEAD COMPLETION <br /> ����. W � � � E T "t,� utside ell House ' rade Inside asement Offset <br /> �� W <br /> �� --;--- --�------�-- --.-- s W � . <br /> � O : U ��AtG • ❑B <br /> `t , � � � Mile Pitless Adapter/Unit � ried ell Pit <br /> h � �W <br /> . , 1 0 <br /> --:--- --T-- ------ ----- <br /> - ❑Buried <br /> S ❑Well Pit <br /> �y ❑Other <br /> f--lMile� �' `p�:_. .}-,�..__ rG ��+ti ❑Other <br /> PFj(�ER�YyO�W�NE '�/ MPC�_ ANY_NAME � CASING(S) <br /> e,:r:a t ilerii�eQ Diame�� � Depth � Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above 2 in.ffom �J to��ft. '��YBS �NO ❑Yes ❑No ❑Unknown <br /> 15Q5(3 23�d Av�e te <br /> P�_`—__1L' �T �� in.from to ft. ❑Yes �]No ❑Yes ❑No ❑Unknown <br /> �+mQu��� •n. <br /> _in.from to ft. �;Yes []No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> i � <br /> Well owner's mailing address it diflerent than property owner's address indicated above Screen from__� to �� ft. Open Hole from __to __ ft. <br /> OBSTRUCTIONS <br /> []Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> Type of Obstructions(Describe) _______ <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑Na Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby weil or boring. <br /> � • � r � TYpe <br /> e--�r-� � ��•'`� L.Removed �Not Present ❑Other __ <br /> / METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exisis ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> i <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> /�/ � � <br /> Grouting Material/v�l�T�mFitJ� from � to�� fl. yards_Z_ bags <br /> from to ft. yards bags <br /> ______ from to ft. _ yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? � �Yes ��No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The in(ormation contained in this report <br /> is true to the best af my knowledge. <br /> D�n Stodols t�e11 t�cill�n� Co,. Inc. 1591 <br /> Licensee Business Name License or Registration No. <br /> , � <br /> , <br /> � � :,%�iJ t ..J <br /> C "e esent ive Signatur2 _ � Certified Rep.No. Date <br /> LOC�,_.: ,�PY H 2 9 0 0 9 4 � ..�t ✓�s; ,,.�Qrs�,,,,� - <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 �� 9'09R � <br />