HomeMy WebLinkAbout1993-11-23 Water Well Sealing RecordMinnesota Well and Boring
WELL OR WMNGLOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No 1H 7 O
County Name -- - WELL AND BORING SEALING RECORD Minnesota Unique No ---
Minnesota Statutes. Chapter 1031 or Wsenes No
i�nnet;in ,IP•rlUNrV,.r,¢M.,.ri.., �---------- -- -----
Township Name Township No Range No Soclwn No Fraction Ism • Ig I Dale Sealed Approximate Date Well
Li t l is 11 ` (. J ' ' ' 1 — -'A' .. Gq , or Boring ConstructedM
Nhanonral Street Address or Fire Number
n
and City of Well or Bog Localion
2 1 t' C011ill LWjl,-t' ] Xr,(j J.cilZl` a N4.- - ., . Depth Before Sealing II Original Depth
Slow esad location of well or boiling Sketch map of well or toting SlaW Water Level Accurate
in fiction god with X leu cion showing properly lines
N roads and buildings ❑ Appro■imale
Single AiT,rder ❑ Multiartuder _�` n habw above land surface
WING TYPE
W
1 1 1 1 • /f Ufa
1 1 1 1 ,•rte y `•I,.i i_1 Pla5tic ❑ Tile U Olhei
�- -
!T!1+1 -1 t�
Scree, from — .e -- If Open Hole from to it
1� S
OSSTRUCTIOWDEERIEIFILL
Obstruction ❑ Debris ❑ Fill
PROPERTY OWNER'S NAME
P•�I'�'7 i. '.�t;T-,r .•til 1
__----— - -- - - Type of debris obstruction
Mailinil Address if different than properly address indicated above
ODstnictwnrDabnsFsl removod' Vee ❑ No
PUMP
❑ Removed ftl Preset" ❑ Other
CASING
Diameter Depth Set in oversize holey Annular space initially grouted'
in from � to — _� ft El`,y" Yes t�Nu ❑Yes El C1Unkrw
in from to _.— It ❑ Yes El No ❑ Yes ❑ No ❑ Unkno
It G re, ❑ No ❑ Yes ❑ No ❑ Unkno
GEOLOGICAL MATERIAL
COLOR
HARDNESS OF
FORMATION
FROM
---
TO
-
It not knownindicate estimated formation log from nearby well or twang
1
-- - - -
USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND SORF MOLE:
u Annula, Space E.isls
nnular space grouted with tremae pipe
asing PedooatiorvRemnval
f
REMARKS. SOURCE OF DATA, DIFFICULTIES IN SEALING
Grt Lt Well 7"
L i q's corelnt.
a ljl*;. k3 %ni- xIl to
L Wr.E Ji sr t;iE Rite ailnor"t Cb,en't (07rut F).l;
H 46706
in from to it ❑ PoAwaled ❑ Removed
in from to it ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL
Groutingmatenal � t. t Brom to
born . to _ 11 yards
from _ to if yards
from to if yards --_ bags
UNSEALED WELLS AND BORINGS
Othei unsealed well w miring on property'/ ❑ YesNo
LICENSED OR REGISTERED CONTRACTOR CFR 1111-KATIbIll
This well or twang was sealed in accordance with Minnesota Rules Chapter 4715 The ,nftomalion corlained ,e th,S leprid is
true to the txsl of ray knowkWQTa
iN•_!L1JN6 l,_ . i.t'.
Ccwtrachm Busmeas Name L icense w No --
""I've S"b"
13. =.rte Mkt ,
Alanre 01 Peistr, Seating WMl ur Swing
uale