HomeMy WebLinkAboutWell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 3 6 3 8
WELL OR BORING LOCATION Sealing No.
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
Minnesota Statutes,Chapter f031 or W-series No.
(Leave blank if not known)
Township e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed 1 Date Well or Boring Constructed
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Numerica Street Address or Fire Number and City of Well or Boring Location
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Depth Before Sealing �� ft. Original Depth J0� ft.
Show exact location of well or boring Sketch r�p of �I�wr boring A�UIFER(S) STATIC WATER LEVEL
in section grid with"X". location, s g properry Single Aquifer ❑ Multiaquifer
-�— nd buildings.
N WELUBORING ❑ Measured �Estimated
� � � � - �iVater Supply Well ❑Monit.Well �
'Y' 'Y' -'l-' '-1--
� ❑ Env.Bore Hole ❑Other �ft. �elow ❑above land surface
� � � � T '
W --�- -;-- -i-- --;-- E � CASING TVPE(S)
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� � � i -:�,.,
--�- -�-- -i-- --�-- � Steel ❑ Plastic ❑Tile ❑Other
'/.mile
--�- -�-- -�-- --�-- � CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
L� i
y(�1 mile� ��n.from� to�� ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown
I
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown
Property owner's mailing address if different than well location address indic�ate}d above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknoti:�n
�J-R-j-o�y _ C_� r t'�e�-1 SCREEN/OPEN HOLE
r �
Screen from�to�� ft. Open Hole from to ft.
OBSTR UCTI O N/D E B RIS/FI LL
WELL OWNER'S NAME �bstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill �(�D /C[J�/ 1 tL /��P1//'��.J
Obstruction/Debris/Fill removed? �Yes ❑ No
PUMP
Type
GEOLOGICAL MATER�AL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log rrom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exits
_ ,_. _ _ Annular space grouted with tremie pipe
- ❑ Casing Pertoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
t
❑ Other
GROUTING MATERIAL(S)
. � �` Grouting Material � � �om � to f/S/� ft. yards �� bags
! vC/
from to ft. yards bags
from to ft. yards bags
a
from to ft. yards bags �`
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
� Other unsealed well or boring on property? ❑ Yes No
LICENSED OR REGISTERED CONTRACTOR CERTI C ION
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.
Ibn Stodola i�e3l Drillir� Co., Inc. 27172
Contractor Business Name License or Registration No.
��.. /--�� // .. _ .�__.�-�--" - /`r .! _
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-,_ �/! ..��
. " �-7 ` p .
�lytiiqn�d, p�Esenta e Signature Dat�
......"..... .,' r ,, ��.l�::a`f'�..i
�+ �j Name of Person Sealing Well or Boring��
LOCALCOPY H � � � p � p
HE-01434-02 10/95R