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Home My WebLink AboutWell info wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �3 5 9 3 4 ` WELL AND BORING SEALING RECORD M nnle oNa Unique Well No. County Name ; Hennepf n Minnesota Statutes,Chapter 1031 or W-series No. (Leave dank il�wl krwwn) Township Name Township No. Range No. Seclion No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed OrOQO 117�T 23W 20 �,. �,. �,. Z� /)'l�jY' G?S GPS t-atitude degrees minutes seconds (� � LOCATION: Depth Before Sealing 2�� , ft. Original Depth � +� ft. Longitude degrees minutes seconds pUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Muldaqu'rfer 275 Carman Rd OY'OItO�.MN. 55331 WEL.UBORING �Measured ❑Estimated �Water Supply Well ❑Monit.Well i Show exacl location of well or boring Sketch map of well or boring [f� in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other /� ft. �below ❑above land surface N lines,roads,and buildi�s. CASING TYPE(S) �Steel ❑Plastic ❑Tile ❑Other W --�- -=-- -=-- ----- E � WELLHEAD COMPLETION � � � � � �� Outside: -Y- ---- -�-- --i-- ❑Well House Inside: ❑Basement Offset � � � � �� i � �. � �Pitless Adapter/Unit ❑Well Pit —�- -�-- -i-- --i— � ' � S � ❑Well Pit ❑Buried �—"""°—�" � ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diame er Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location ad ress indicated above �/ � in.from� to�ft. ❑Yes �No ❑ves p rvo ❑umcnown in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.frOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE i � Well owner's mailing a ress i i eren t an pr perry o e r in SCfeen ffom�to��ft. OpOn Hole from to ft. P.O. BOX 35 ossTRucnoNs ` M21 55357 }ea Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction g Loretto, . �, '�b��t�79..,(�3�� TypeofObstructions(Describe),,,f11.�-XJ� 1�.1� R �J GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 8S ❑ NO Describe FORMATION If not kno n,indicate estimated formation log from nearby well or boring PUMP Type_�1� �tJl/'t� �.�� """' '�Removed ❑ Not Present ❑Other 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 in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Pertorated ❑ Removed Type of perforator , ❑ Other GROUl1NG MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonfte=50 Ibs.) /} yry �} r �/� Grouting Material �Q��t�+t„�!/��from�_to�i.i[. yards �.�,L bags from to ft. yards bags from to ft. yards bags OTMER WELLS AND BORINGS ' REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.TMe information contained in this report is true ro the best of my knowledge. . - DON STODA7�A WELL 1��Ti.T.TtaG ��.� ��,J� T, �� Contractor Busme Name L�cense or�s�a�o��. ��'�� -- � ��fJ lr'�.i horized"Representative Signature Date \� f''�` - �... H 2 3 5�3 4 ��- �:..��.,�V,.,�-�... LOCAL COPV - - � Name of Person Sealing Well or Bonng � - � _ - ---- MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring C C(��Q WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Menn'eso a�Unique Well No. H �j V�J 0 County Name Minnesota Statutes, Chapter 1031 °edW serieskNo. Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Dafe Well or Boring Constructed ,, ,, 9 �� . GPS Latitude degrees minutes seconds Depth Before Sealing� ft. Original Depth _ft. LOCATION: Longitude degrees minutes _ seconds - IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �ingle Aquifer ❑Multiaquifer �/ai�/ /�y�� = p W WBORING �Measured ❑Estimated Date Measured�� Y � nd � 3 ' 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 property L�Env.Bore Hole [.;Other � U ft. �below ❑above land surface N lines,roads,and buildings. CASING TYPE(S) i --'----`-- ---`— --'-- �'..r..�.. ��.. � � � j �. �� Steel ❑Plastic ❑Tile ❑Other � � � •�� ' --'--- � --`-- ---`-- � �� WELLHEAD COMPLETION �� —i--- - i � , � , w ; ; ; : ET ._._- - " , __�____,__ _� __�_ Outside: ❑Well House �_j At Grade Inside• ❑Basement Offset � 'hI Mile ❑Pitless Adapter/Unit ��Buried ❑Well Pit ---- - I ❑Buried : L ❑Well Pit ' S ❑Other n �1 Mile� ❑Othef ��r�t="u �xT frZ PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) Dia ep� i Depth I Set in oversize hole? Annular space initially grouted? Property owner's mailing addres different ihan well location address indicated above � � �Z I�I � f� �� ❑Unknown in.from to ft. Yes No _ Yes No 565 Big Woods �1� in,from to ft. ❑Yes [�No ❑Yes ��No I]Unknown Chsnhass�n, �T 55317 in.from to ft. �_�Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � � I ; Well owner's mailing address if different than property owrer's address indicated above Screen trom_ 1,7�_ro�ft. Open Hole from to ft. � ` OBSTRUCTIONS �Rods/Drop Pipe ❑Check Valve(s) I']Debris ❑Fill r]No Obstruction Type of Obstructions(Describe)..L./v��` �.�� " �Gf/��.� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?�Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � �/ - -Jf�� Type�CJI� �vmD f" � '�� '^ emoved �.�!Not Present ❑Other a METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CAS�NGS,OR CASING AND BORE HQLE: � No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to R. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator []Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ,�!-�V,�y► r •��-f Grouting Material/�/L/5" �-""„��T from�__ to��_"__ ft.______. yards �� _ bags _ from to ft. yards bags i. __ from to_ ft. yards bags ' OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES iN SEALING Other unsealed and unused well or boring on property? ��-J Yes�No How many?_ _ LICENSED OR RF_GISTERED 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� stodola Weli ncilii�Co,. inc_._ 1691 � Contractor� sin ss Name .-� � � License or Registration No. ` `' �"� `� 1 -' � �`'—� � " `-' -t' -- -- C ified Representative Signature l Certified Rep.No. Date Name of Person Sealin Well or Borin �� - " 256098 ��-- � , LOCAL COPY �,.—� ' j �""ipW�---�-�— ---—._ 9 9 HE-01434-09 IC#140-0423 . s/osa