HomeMy WebLinkAbout1993-09-14 Water Well Abandon RecordMltltt.solE Wee and 8wnq
RL Olt MOIr/OIOCATION MINNESOTA DEPARTMUx ENT HEALTH Seawg No
sou 429 0 3
courant Name WELL AND BORING SEALING RECORD --oast ore No
Minnesota Statutes Chaplet In a%
Tasmsh,p Name Tuwnsha, No Range No Section No tg I Date Seaierf Appronmate Date Well
11,molon,sin
Cris t< 11 I s - - rri I- I t-I `1 , &,r� q eu s,nMted
Nutnetr al Slreel Address or Fire Numbet and C,ly „f Well or gor,rg Lncal*.
- t' i't1!•r � T i.A)w 16U. lTtxk" f`rl.
Depth Before Sealing _ ( J L h
`
OrgnatDepth
Show exact lofalrerl of "I w boning
S4etch reap of well or boring
Slat•[ Wale, Le l Accurate
n function grid with X
location showing property Ines
❑ Appro■—ate
N
roads and budd.ogs
Single Aguder Cl Mulbagullec
r_ n -.— -- below above land surface
r �
- ' - - • - -'-
CAfIM TYPE
iIV r
r I �
r
t.Y
Sleet ❑ Plastic ❑ Toe ❑ other
I�
r r
r V'
S
r.
Screen from to fl oparl Hole from to n
ODiT11UCT10WDEDIMlIle141
�1
❑ Obstr,rctron ❑ Debris El Fill
wTDPE1m OWNER'S NAME
Type of debrwobstructron V v j r
Mailing Awhess d ANetenl than property addess vndrealed borne
ObelnrcftOrJOebrrLftN rwrwved' Vex ❑ No
li.jl''. imtic-s Ridge
PUMP
Rim Prairie, MN.55�0
❑ Removed Not Present ❑ ofMl
CASM
tee/ Depth Set in overslts hole' Annular space ntraNy grotrsed�
from - to �' IF ❑ Yes ko ❑ Yes ❑ No n UnluWal
n from to If ❑ Yes ❑ No ❑ Yes ❑ No ❑ unknown
_ in from to If ❑ Yea ❑ No ❑ yes ❑ No ❑ Umnowl
OEOLOOICAL MATUMAL
OOLOII
f n OF
NI011
TO
S no U,nwn, ndcaN esbruted IomWgn tog from nearby ImIl or bang
O
Ilse
—
ISTTTOO USED TO SEAL ANWAAM SPACE WTWM S CASt110S. ON CASH AND 0011E "OLE:
No ArnlAar Space Exalts
❑ Annular space grouted with trwtue pipe
❑ Cal ng PeAaatnrvRartloval
n from to n ❑ Pwtwatw ❑ Removed
in from to n ❑ Pookmm ad ❑ Rwnoved
Type of
'
t
.•
perforator
❑ Ohw
— U E
6
ONOUTNO MATE1MAL
Groutng material + ` _ Yrom L _ to n yard bimp
from to n yards begs
MNAMfS. WUPCE OF DATA. D/PCMTXS 0 SEAh1M1:
From to h yards page
30bw
from to h yards begs
IMgEAIED WELLS AND OOIMIOS
2 men labwE Sig i cement gI pW
unsealed aa bang on property' Ores
NSED 011 IIEOSTEIIED COMTIIACT011 C911111`1111116ADMI
LICENSED M
This wee or boring was sealed in accordance with Mwnesola Rules Chapter 4725 The information cor•taned in fhrs ,epon .s
True to the test of my knowbdge
14 d: :11i11 lLr'. rl►i: i.[ r U U dAINC c'l
Cont,acfo, Business Nance Lcense or Reg stratio n No
------9-1 "3
1 prpsPnlA 11Y• yn3lu,P ()Jm
_� ---- - - - --- ----
H 42903
NAmr• ::r Person Seal.g Well or liavg
HE-01a11 '�