HomeMy WebLinkAboutWell & Boring Sealing RecordLatitude Longitude
AQUIFERS) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location � Single Aquifer ❑ Multiaquifer
�' +*� . �. � � � WELL/BORING � Measured Date Measured % � , `.) ] Estimated
Water -Supply WeII ❑Env. Well iA
Show exact location of well or boring Sketch map of well or borin
in section grid with "X ° location, showing property ❑Temp. Boring ❑Other ft. � below ❑above land surface
N lines, roads, and buildings. � CASING TYPES)
W
�I
'�.
E
T
'h Mite
l
s
'--t Mile
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page. `
PROPERTY OWNER'S NAME/COMPANY NAME
"� ] � [� Steel ❑Plastic ❑Tile ❑
WELLHEAD COMPLETION
�'
Outside: ® Pitless Adapter/Unit
''
❑WeII Pit
❑Other
t,.!
Property owner's mga+ili�ng ad{d�ressyif different than well location address indicated above
J # i,F 2
€i�.f .. '
•�� �:rr •u•:� �:u
property
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM
FORMATION
If not known, indicate estimated formation log from nearby well or boring.
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
❑ At Grade Instde: ❑Basement Offset
❑ Buried ❑Well House
❑ Well Pit
❑ Buried
❑ Other
CASINGS)
Diameter Depth
in. from � to ft.
in. from to ft.
in. from to ft.
SCREEWOPEN HOLtE
Screen from `'� to � ` ft.
,,O��BttSTRUCTIONS
I�RodslDrop Pipe ❑Check Valves)
Set in oversize hole? Annular space initially grouted?
❑ Yes ❑ No ❑Yes ❑ No � Unknown
❑ Yes ❑ No ❑Yes ❑ No ❑Unknown
❑ Yes ❑ No ❑Yes ❑ No ❑Unknown
Open Hole
from
to ft.
❑ Debris
❑Fill
❑
No Obstruction
Type of Obstructions (Describe)
Obstructions removed? � Yes ❑ No Describe
PUMP
TO ❑Not Present � Present, Remov�erd Prior io Sealing ❑Other
Type �i�s,
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
[�No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
Casing Diameter
in. from to ft. ❑Perforated ❑Removed
in. from to ft. ❑Perforated ❑Removed
Type of Pertorator
VARIANCE
Was a variance granted from the MDH far this well? ❑Yes � No TN#
GROUTING MATERIALS)
Grouting Material -rr� �,�'�.,�Trom�, to ft. yards bags
from to ft. yards bags
from to ft. yards bags
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.
Licensee Business Name
License or Registration No.
1�/