HomeMy WebLinkAboutWell info MINNESOTA DEPARTMENT OF HEALTH Mmnesota Well and Bonng �H � `��^O �
YYELL OR BOIi1NG LOCATION Sealing No j� L
�,,� WELL AND BORING SEALING RECORD Minnesota Unique No —
Minnesota Statute.s,Chapter 1031 or W-series No. I
� ILeave blank il not known) _J
Township Name TownsMp No. Range No. Section Na Fraction�sm.i Ig.) Date Sealed Date Well or Bonng Constructe�
� + �J� �} . C..� /" �� , _
!
Nunencal Streel AAdress a Fire Number and Gry ol Well or Bonng Localion '
Depth Beforr,Seahng �.�y> _N. Original Oepih - ���' n
SAow enad loration d�aell a Donng Sketch map of well or bonng AOUIFER�S) STATIC WATER LEVEL
� n section gnd wrM�'X'. locauon, showing property ,�Single Aywfer ❑ MWhaqwfer
lines,roads,and bwldings.
N WELUBORING �Aeasured ❑ Eshmated
� Y� _
'�Water Supply Well ❑Monit.Well
-�- -�- -�- -'-- f ❑ Env.Bore Hole ❑Other �' �'�� fl. �bebw ❑above land suAace
W --'r-- -�-- -T- -i-- E t��d��.' �� CASING TYPE(S) —
4. ;.s'
-T- -i-- -i-- -i— � � ❑Steel ❑ Plastic I�Tile ❑Other (�%; - `�fr�
� � � � um�e .. .,';:. � . ..
��t.
-�- -+- --I-- -�-- � . -�, . .� CASING
t"` �-% Diameter Depth Set in oversize hole? Annualar space inrtially grouted?
S .��.+�-`in.from f___� to�•� ft. ❑ Yes �No ❑Yes ❑No ❑ Unknown
����
PfiOPERTY OVYNER'S NAME ��� in.from _ " to ' `� ft. ❑ Yes 0 No ❑Yes ❑No ❑Unknown
Rape�ry o.rers maing address a dAferent Vian we�l�ocation address indicated above. -'� in.from �',�-� to "� � R. ❑ Yes Q No ❑Yes ❑No ❑ U�known
SCREEWOPEN HOLE
Screen from to R. Open Hole from to ft.
OBSTRUCTIONS
������ � Rods/Drop Pipe ❑Check Valve s
( ) ❑ Debris ❑ Fill ❑ No Obstrudan
YYN owrfs addiass R QllsierM t�an owners address indicatetl above. � l-� �'�'� '
m�irq property Type of Obstructions(Describe) �`
Obstructions removed? �Yes ❑ No Describe
PUMP
:i �.� �: � .�.1
Type •/ -'
������ �� HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
q not laq�wi,iidra�s siYtiedlortnaeon bg}rom nearDy well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
. �No Annular Space Exits
Y w �f �'� ❑ Annula�space grouted with tremie pipe
❑ Casing PeAoratioNRemoval
in.from �o ry, ❑ Perfaated ❑ Removed
in.from to ft � ❑ Perforated ❑ Rertroved
�
Type of perforator
❑ Other
GROUTING MATERIAL(S)
� „� � �J
GroutingMatenal `�'��`�'' S from to� tt. �-^�^� yards bags
1
��.�.'�/. :�JN, (<• ffWll t0 �I- y8ldS _;_„�;1 bep8 �
trom to n. yerds degs
from to_— ft. yards bags
RHIAitl�B,80UiCE Of DAT/�OFRCULTIES IN SEALING OTHER W ELLS AND BORINGS
Clther unsealed and unused well or boring on property7 ❑Yes ❑No How man�/t
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
- . This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The i�ortnation oorMained in Miis report is
. true ro t�e best of my knowledge.
s t,,;,:;. l�on Stodola t�el2 Drillin� Co. Inc. 271.72
�,)�� � � ,° Contredor Business Name > ,� Lioenss a Re¢stra0on ivo.
.. � :, �',` �...�--`,.,,,����� Z� �* �1
f � � ` �
�t oriz R resentative Signature.- De/s P
H ����A O Name o!Person Sealing Well or Bonng
LOCAL COPY ��
:� tE-01�-03 2/97R