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Home My WebLink AboutWell info ' wELL OR BORING LOCA7iON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 5 6 3 County Name WELL AND BORING SEALING RECORD MennlesoNa Unique No. enne �.Ii Minnesota Statutes,Chapter1031 or W-series No. (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed ronu l I7 23 17 44-t�OZ j� �;,�F Numerical Street Address or Fire Number and Ciry of Well or Boring Location ~ �, � 4��J Da�Q�eQ T�SL'e 3 OrQIIO 5 S 392 Depth Before Sealing '��Z-� ry. Original Depth � ft. Show exact location of well or boring Sketch map of well or boring A�UIFER(S) STATIC WATER LEVEL in section grid with"X". ; location, shawing property Single Aquifer ❑ Multiaquifer lines roads,a b ildings. N :'i�, � '�� - ��`�..�. W UBORING �Measured ❑ Estimated � � � �._ Water Supply Well ❑Monit.Well � -i-- -i-- �,/ 4�� ❑ Env.Bore Hole ❑Other �ft. I�below ❑ above land suAace � � � � __..._.�...__._..._.._._.__ W —�- -�-- -i-- --i— E CASING TYPE(S) - � � � � � � � � , --�- -�"- -�-- --�-- � �.Steel ❑ Plastic �Tile ❑ Other Y.mile --�- -�i-- -�-- --1— � ._.._,,,,,,,,,,,,,_._..___.._....._ CASING , Diame�� . Depth f Set in oversize hole? Annualar space initially grouted? 1 S 1 """��J�� '1 /� �r m��e--q�, �7 � in.from S� to Z� � tt, ❑ Yes �No ❑ Yes ❑No ❑ Unknown I ROPE T OWNER' NAME in.irom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown �an�`�at �urneic�e �20-9466 Properry owner's mailing address if ditterent than well location address intlicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE i !1 ;`: ,� ,y�'�, Screen from �� f to �� ft. Open Hole from to R. J OBSTRUCTIO WDEBRIS/FILL WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mailing address if diHerent than properry owners address indicated above. Type of ObStructioNDebris/Fill �/�1�/f�`�� / .�/�� ' �1/�1�� Obstruction/Debris/Fill removed?�Yes ❑ No PUMP Type �U� /-!1/�� GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other FORMATION If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � _ i •'i No Annular Space Exits i,�) �.:�cX. � � ❑ Annular space grouted with tremie pipe �,'f ❑ Casing Perforation/Removal in.from to ft. ❑ Pertorated ❑ Removed in.from to ft. ❑ PeAorated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) Grouting Material ��/�� /��•f✓1��m � to� ft. yards �_ bags from to ft. yards bags �� from ro R. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes o LICENSED OR REGISTEREO CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoR is true to the best oi my knowledge. Don Stodola W�II Drilling Co., Ine. 27172 Contractor Busmess Name f License or Registrallon No. _..--� , f ,�/' -� ��f 1 ,%�j,�.�'�f l i��i ti':. i �` ! Aut�rl ed Representative Signature Date •; - �,.', �1 -{�-. ��' �. ,1.t.�_ `, �y..,._;v`-�. LOCAL COPY H 12 4 5 6 3 Name ol Person Se¢ling Well or Bonng HE-01434-02 10/95R WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 5 6 4 County Name WELL AND BORING SEALING RECORD M nnlesoNa Unique No. Minnesota Statutes,Chapter f031 or W-series No. n (Leave blank it not known) Township Name Township No. Range No. Section No. Frection(sm.�Ig.) Date Sealed Date Well or Boring Cons[ructed rono 11 23 17 4�4-()fl2 /`� t�a:� �-r ? � Numerical Street Address or Fire Number and Ciry of Well or Boring Location �)! � 2�� B� iew Pla�e �r�n� 5 5 39 Depth Before Sealing �L/ tt. Original Depth �y fl. Show exact location of well or boring Sketch map of well or boring Ap IFER(S) STATIC WATER LEVEL in section grid with"X". location, showing property �ingle Aquifer ❑ Multiaquifer lines,roads,and buildings. �/ N WELL/BORING �J Measured ❑ Estimated � � Water Supply Well ❑Monit.Well / - - - - -;-- --;— /�/ � ❑ Env.Bore Hole ❑Other `"`"`��} ft. �below ❑ above land suAace W —'r-- -i-- -i-- --i— E � _"_ __ CASING TVPE(S) --�- -';"' -�-- �-�-- � Steel ❑ Plastic ❑Tile �Other %mile -_�- -�-- -�-- --1-- � CASING Diameter Depth � Set in oversize hole? Annualar space initially grouted? �L"" S "�" /� �^: �r,—r mi�e� :?� � �Y � in.from �✓ ro �� R. ❑ �es �No ❑ Yes ❑No ❑ Unknown I PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown Dan Pat 33urneice 420-9466 Property owner's mailing address if difterent than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown /., SCREEWOPEN HOLE / �� `�"� Screen from � to ��j/ ft. Open Hole from to ft. OgSTRUCTlO WDEBRIS/FILL WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill�No Obstruction Well owner's mailing address if different than property owner's address indicated above. Type of ObstructioNDebris/Fill Obstruction/Debris/Fill removed? ❑ Yes ❑ No PUMP Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed � Not Present ❑ Other FORMATION H not known,intlicate estimated tormation log trom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �� } �, ��J1 No Annular Space Exits `"� ��` ❑ Annular space grouted with tremie pipe i ❑ Casing PerforatioNRemoval in.from to fl. ❑ Perforated ❑ Removed in.from tp ry, ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) 1 l/-�%, ,- � �r- ^7�} �: Groutlng Material2 - �l��?``d'f'�rom � to� ft. yards � bags from to ft. yards bags from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes ❑ No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 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. Don Sbvdola vel2 Drilling Go. , Inc. 27172 Contracfor Business Name License or Registrallon No. �'r/'r.j�./f' . ��-�. ��-^'fiS_% r�..� �� f " �Autfiorlied Representative Signature Date ;�--.-,.� i�-; ��ti.,�jy`�,,, LOCAL COPY H 12 4 5 6 4 Name o/Person Seali�}g Well or Bonng HE-01434-02 10/95R