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