HomeMy WebLinkAboutWell info WELL OR EORING LOCATION MINNESOTA DEPARTMEN7 OF HEALTH Minnesota Well and Boring I„I ����C C
Counly Name
WELL AND BORING SEALING RECORD Minn�e90 a�Unique Well No. v V
Minnesota Statutes,Chanter 1031 or W-series No.
�"' �Leeve blenk'il no�knownJ
{ Township Nam Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construded
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GPS Latitude degrees . _ minutes.__ __ seconds Depth Before Sealing �� ft. Original Depth _ft.
��� LOCATION: Longitude degrees_ minutes__.__. seconds ��
�UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and Ciry of Well or Boring Location ,. Single Aquifer [�Multiaquifer �fn.� A/1
WELUBORING _;Measured [�Estimated Date Measured.�!""!"� `.lI'��
1 .]Water-Supply Well [�MoniL Well �
Show exact location of well or boring Sketch map of well or boring i Env.Bore Hole � �I Other f ft. �j below above land surface
in section qrid with"X:' location,showing property �- — � U
lines,roads,and buildings. -�
: N CASING TYPE(S)
:. _L— —'-- --`--'—'- n;t
tr�j}1�h�� �� ���� ��Steel �Plastic [Tile _j Other _ _
!�
' --�--- --�--- ---`-----'-- WELLHEAD COMPLETION ��
. W , ET _
; ; ___ __ r__ Outside: j]Well House _At Grade Inside: �Basement Offset
i
'h M��e P�� � �� ;,�Pitless AdaptedUnd `:Buried ❑Well Pit
A --,--- --.--- ---�-----:-- 1 � _
_,�Well Pit ❑Buried
S ❑Other
�-1 Mile—� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Qj�jl,f� � Diamet�,r� + Depth Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location atldress indicated above S � t� u � I� n ��Unknown
in.from to ft. Yes No Yes No
in.from to ft. ❑Yes ❑No ❑Yes �f No [_.Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No [Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
� r
�
S Well owner's mailing address if different than property owr,er's address indicated above SCreen from___��� to__�� R. Open Hole from____,___ _ _to __ ft.
OBSTRUCTIONS
��._.J Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction ��
5
'� Type of Obstructions(Describe) '
GEOLOGICAL MATERIAL COLOR HARDNESS oa FROM TO Obstructions removed? ❑Yes C No Describe
FORMATION
PUMP
If not known,indicate esfimated formation log from nearby well or boring.
; � . 1 ^� TYPe `,
�� /�r- �J ..;)vC .� ;
.�� �. J Removed '��,Not Present �, �..Oiher____.___._______________.___ !
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ;]Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
❑Other
. GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material f���% �F J�.L��rom_�• to J� I ft. yards� bags
_,___ from _ to___ ft. yards bags
from _ to ft. _ yards_ bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES iN SEALING Other unsealed and unused well or boring on property? ❑Yes �� No How many?______ __
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.
� �n_�_totala ieiell Drilling_ Co---- --1691 ----- :
Contractor Business Name License or Registration No.
. � . �'�' i.'��- �i� �
i epresentative Signature� �� � Certrfied Rep.No. Date
,ti
LOCAL COPY H 2 616 6� ��;�Y� -��f`��YY�
Name of Person Sealing Wel!oi Boring �
HE-01434-09 IC#140-0423 6/Osa