HomeMy WebLinkAbout05-02-1997 Well & Boring Sealing Record�' - - - � _
WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �18 414
County Name
WELL AND BORING SEALING RECORD Minnle9oNa Unique No.
Minnesota Statutes,Chapter 1031 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
Qrono 117 23 t}8 45-0'027 /� 9'
Numerical Street Address or Fire Number and City of Well or Boring Location � l �, ♦ �
3'!UQ Bi r ch Lane QXOn� 5 5 39I Depth Before Sealing • 7 R� R. Original Depth /�_7 ft.
Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property Single Aquifer ❑ Multiaquiter
��y s, nd buildings.
N „�--�"'� �,� WELUBORING Measured ❑ Estimated
' ' Water Supply Well ❑Monit.Well �
_ _ _T_ _ __ __l__ w
T � J
I I ! I ❑ Env.Bore Hole ❑Other_ _.�, s�ft. �below ❑ above land suAace
__f_ _l__ _l__ __l__ -• .r
W E -� ` CASING TYPE(S)
� � � � e',�.
� � � � ��
--�- -�-- -�-- --'�-- ,?,L� Steel ❑ Plastic ❑Tile ❑Other
14 mila '
--�- -�-- -�-- --1-- � CASING
�� ._:w,.
�->'� Diameterf Depth / Set in oversize hole?
S . Annualar space initially grouted?
�r mxe--q�e �� , - � �_ in.from � to�L ft. ❑ Yes �No ❑ Yes ❑No ❑ Unknown
I
PROPERTY OWNER'S NAME in.from to tt. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
�i13 i ward 4?1-i3��i
PropeAy owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
r,,, i �
Screen from�to� ft. Open Hole from to ft.
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address if ditferent than property owners address indicated above. Type of Obstruction/Debris/Fill �/�/V'��< /""l-NT � V LJ
Obstruction/Debris/Fill removed?�,,.Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
- � �No Annular Space Exits
._...,� ' _�.-1' �"� ��'� ;`y�..::,
j1
❑ Annular space grouted with tremie pipe
❑ Casing PerforatioNRemoval
in.from ta ft. ❑ Perforated ❑ Removed
in.irom to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
��' ���^'' f
Grouting Material/�'���� �����1Fom � t���,j_ ft. yards � bags
from to R. yards bags
from to ft. 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 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 Stodola tde21 Drillin�; Co. , Inc. 27172
Contractor Business Name License or Registrafion No.
+_...__�% . - ; ,«..,
''�-- . .� �'� �,` t j l
Authorized epresentative Signature Date
1
` 'f .,. _ � ;.�_.i,1�� ...�;
LOCAL COPY 118 414 Name o/Persoq"Sealing Well or Bonng
H
HE-01434•02 10/95R