HomeMy WebLinkAboutWell info Minnesota Well and Boring 7 (�
WELL OR BORING LOCaTiON MINNESOTA DEPARTMENT OF HEALTH Sealing No. H � 1 O�'J
co���v Name ���� WELL AND BORING SEALING RECORD orlW series No.ue Na
Minnesota Statutes.Chapter 103/
�Leave biank�f not k�own)
Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
,ry or Boring Constructed
C��10 117 �3 16 �i�+,—U(���',q c
Nume�i�cyal Str�ee�t A1.d�,d.�re,�s,s or Fire Number and City of Well or Boring�ocation � ` �
17L� wlui7 rL. i�1lA. vi(jt]Q� r,aj� DepthBetoreSealing ���/ ft OriginalDepth �`� ft
Show exact location o(well or boring Sketch map of weli or boring Static Water Level �Accurate
�n section grid with��X��. ". location.showing property hnes.
��-;;- roads.and buildings. ❑Approximate
N
i i i i_ y.. /
-; -;- -;- -�
'--,j, Single Aquifer ❑Multiaquiter —�.�—fL � below above land surtace
i i i i
_i_ _�_ _�_ _i_ CASING TVPE
W i i � i E
� � � i T
-r -�- -r- -r T
i i i i '�e j y+�` Steel ❑Plastic ❑Tile ❑Other
�.�
_i i i i_ �� ' e
i _i_ _i _ _i { �, / I
,; ! fa
t ._ ...�.�� _ Screen from� to � fl. Open Hole from to ft.
S
N--i m7e--�I OBSTRUCTION/DEBRIS/FILL
- PROPERTY OWNER'S NAME �Obsiruction ❑Debris ❑Fill
Taylor Lauer Constrct�on, Inc.
a i..�.us`iP �.!`i°f_. 4 �ml�
Type of debris/obstruction
Mading Address rf different than property address indicated above.
�-,r-,-� ��t� � Obsiruction/Debris/Fillremoved? Yes ❑No
�_}L i.;ZS �
PUMP
�`ti;�t��li:, ri�t. �`_>±lb
�temoved ❑Not Present ❑ Other �„�J� ��m�
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole7 Annular space ini[ially grouted7
- If not known,indicate estimated brma�ion log from nearby well or boring. �
� �
Q ��ls �in.from �to � it. ❑Yes �No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown
� in.from 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
'l '� ❑Annular space grouted with�remie pipe
� _
.�� � ❑Casing Perforation/Removal
i
in.from �o ft. ❑Perforated ❑Removed
in.irom to tt. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
/ i
Grouling material�/��/ �����j from � to !!�/ ft. yards ��bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
- from ro tt. yards bags
from to (t. yards bags
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
Irue to the best of my knowledge.
�J�i 4`�.�lJl.if�� ;h�� aX�.t.i.LL�� �.-L'.� 1�.. c:�� �f.
Contractor Business Name License or Registration No.
....-..%i l� /' ...�- A " �`�,` . C7—�GT3`f �
��
�aT� t�d epresentabve Sgnature Date
I.00AL C;OPY H 5�O 2 O `I�il� A21tO�OLi
Name ol Person Sealing Well or Boring
., i H601434-01