HomeMy WebLinkAboutWell info Minnesota Well and Boring 419 8 �
� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o���Y Name WELL AND BORING SEALING RECORD M���esota u��q�e No.
Minnesota Statutes. Chapter 1031 or W-series No.
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Township Name Township No. Range No. Sechon No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
or Boring Construc�ed 1
,,, „���, ',4 'r4 ',4 1 — � — �? s / � 5 C%
Numencal SVeet Address or Fire Number and Ciry of Well or Boring Location \
` / /��y � , {� ; Depth Be(ore Sealing ? � a ft. Onginal Depth _ � ? �+�- ft.
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Show exact location of welt or boring Sketch map of well or bonng Static Water Levet �Accurate
m section grid with�-X". location.showing property lines.
roads.and bwldings. ❑Approximate
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I I I I '�(y
� Single Aqulfer ❑Multiaquifer fl- �— below above land surtace
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_i_ _�_ _i_ _i_ CASING TVPE
W i i i i E
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-r -�- -r- -r
i i i i � �1) ��'- S�eel ❑PlasGc ❑Tile ❑O�her
:o mile \ ..--`� �
_i i i i_ I al 1
_ _ _ ___ _ 1 ,�..._+
� ��,� _ r �,�� �.�; Screen from to fL Open Hole from to It.
�---t mi�e—� � OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME �Obs�ruction ❑Debris ❑Fill
�� �� ��
�� ����� ' � Type of debris/obsiruction ' ���..T�'� � � ����-' '� �
� Mailing Address rf different ihan property address indicated above.
Obstruction/Debris/Fill removed? Yes ❑No
.. .r-. P�� PUMP
❑Removed Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
� If not known.indicate estimated formation log from nearby well or boring.
ti �
A ' � �in.irom �✓ to � fL ❑Yes �No ❑Yes ❑No �Unknown
lU
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.irom —to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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 fl. ❑Perforated ❑Removed
REType of perforator
2 lgg ❑Other
GROUTING MATERIAL
1
Grouting material �r_ ' -'� �� from '--1 to ��� � fl. yards �..,L bags
" �,._ � � ;
" - � � from to fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
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.� from to ft. yards bags
'` UNSEALED WELLS AND BORINGS
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' ��J,..,t-�.Y-1 +-.i`;�/:j_ �C;(��''� , O�her unsealed well or boring on property7 ❑Yes No
1
� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chap[er 4725.The information contained in ihis report is
true to the best of my knowledge.
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Contractor Business Name License or Registration No.
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Authorized Ffepresentative Signature Date
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H 419 8 5 j �� < :. , �` � <-,�� ; �- �-, �,
�OCALCGFY
Name ol Person Sealing Well or Boring
���� H601434-01