HomeMy WebLinkAboutWell info (old PID#) WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �4 3 0
County Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No.
Minnesota Statutes,Chapter f03I or W-series No.
(Leave blank i�nol known) �4
Township Name Township No. Range No. Section No. Fraction(sm.�IgJ Date Sealed Date Well or Boring Constructed �
'' '' � ;F/� Url
*� .
GPS Latitude degrees minutes ___ seconds Depth Before Sealing G.�� ft Original Depth ft. �
LOCATION� Longitude_ degrees _ minutes___ seconds A�UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer ❑Multiaquifer t.Rrn� ��� '-.
/�,. �.
145U BcseketC� PbinE Itd, VL� WELL/BORING [�vleasured ❑Estimated Date Measured�
Water-Supply Well ❑Monit Well �
Show exact location of well or boring Sketch map of well or boring �- �/'�
in section grid with"X:' location,showing properry ��Env.Bore Hole ❑Other �_R �below I�_j above land suAace
N � lines,roads,and buildings. CASINGTYPE(S)
> --'--- -'--- ---`-- ---'- '
_ .a Steel , 1 Plastic U Tile ❑Other _ _
�� --'"" `�------`-- ---'-- WELLHEAD COMPLETION ��
W ; ; ; : ET _ _
' ' ' � ' J�.�� Outside:�Well House I j At Grade Inside: '�� ��.Basement Offset �J
'. --�--- --�-----�-- --.-- "'� w �
'h nniie\ r]Pitless AdaptedUnit �_i Buried _�Well Pit �
a
���! --�----�----%- --�- ,;�Buried
S '_]Well Pit �
�—1 Mile� 1 �]Other ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �
Diameter � Depth � Set in oversize hole? Annular space initially grouted?
Property owners mailing address if different than well location address indicated above ��
�i'�in.from_�_ to_���t. �J Yes �No ❑Yes �]No I���.Unknown
�7� t'Yir""'t J11 ��� `iYJ in.from to ft. ❑Yes [�No �Yes ❑No i,_Unknown
Minneapolf s, I�►1 55495
in,from to ft. ❑Yes []No �J Yes ❑No =Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
� /
Well owner's mailing address if diHerent than property owner's address indicated above SCreen from to fl. Open Hole from__��_�to��`ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑Check Valve(s) [�Debris �Fill ❑No Obstruction
Type of Obstructions(Describe����G :� ��� 4- /�i M!7
GEOLOGICAL MATERIAL COLOii HARDNESS OR FROM TO Obstructions removed? es ❑No Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring. PUMP
�' . .TYpe �Ub—�E.��r' ;
' �� '�''"'��-'����•} (� �`�" `� Removed ���.'Not Pr�ent ❑Other -
?,� � � �`�� ,� , METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�o Annular Space Exists ;` �Annular Space Grouted with Tremie Pipe I,J Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated [J Removed
Type of Perforator
❑Other
GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�- � r
Grouting Material�/�/ �/�/��LJ/From� to��ft. yards��bags
from to tt. yards bags
from to tt. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? (J Yes o How many?
" UCENSED 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.
i
� DOYI SCO(�OY.B �ZZ �?L'�.lliII� CO.�_it1C- �4�
Licensee Business N e - � License or Regishation No.
, :�; ,,1 G 7
ertif d epresentative Signa re ` Certilied Rep.No. Date
f
��` �
!';C;F,J_COPY H _ �'',_.. /,�,� raY.."LL..j'�✓�..-�
2 fi 4 3 0 5 Name ol Person Sealing Well or Boring r
HE-01434-10 IC#140-0423 � 5/o�a