HomeMy WebLinkAboutWell info wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„� �/�����
County Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. L
F� in Minnesota Statutes.Chapter 1031 or W-series No.
c�ew ae�n�a ww�+q
Township Name Township No. Range No. Section No. Fradion(sm�Ig) Date Sealed Date Well or Boring Constructed
Oror� 11 23 f� 2 -0033 �,. �,. �,. �..
GPS �ntude degrees minutes seconds
LOCATION: Depth Before Sealing , tt. Original Depth �� ' ft.
Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL ,
Numerical Street Address or Fire Number and City oi Well or Boring Location Single Aquiter °�Multiaquifer
E L/BORING � �Measured ❑Estimated
Water Supply Well ❑Monit.Well t
Show exact location of well or boring Sketch map ot well or boring
in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other ��",,,�ft. below ❑above land surface
N ---Jiaes,sea�e; uildings.
[ CASING TYPE(S)
F-_--w Steel ❑Plastic ❑Tile ❑Other
- W "�- - -- - -- --�-- E �~� WELLHEADCOMPLETION
� , � ;�t�'r , Outside: ❑Welt House Inside: ❑Basement Oifset
—�- ---- -;-- --i--
- � �^'� �Pitless AdaptedUnit ❑Well Pit
' --�- -i-- -i-- --�— � .
❑Well Pit ❑Buried
z S
��nw--�. . ..._ �._c...,..,-.� _
❑Buried
;; PROPERT�Y+OtWNER'S NAME/COAMCPAN—Y/NAME�t �y CASING(S)
J� L1�31�1$ 7 J2�'i��cJ733 Dia� Depth � Set in oversize hole? Annular space initialty grouted?
Properry owner's mailing address if different than well location address indicated above f� �} ,...,/
in.from� t0�.L ft. ❑Yes �(No ❑Yes ❑No ❑Unknown
I�
in.ffom t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.f�Of1l to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
,� Well owner's mailing address if different than property owner's address indicated above Screen from�_t0�_ft. Open Hole from t0 ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe),�f�,/���.���a.���
. �
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0S ❑ NO Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
Type
� Removed ❑ Not Pres t ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �o Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
in.from to ft. ❑ 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.)
Grouting Material���(��11F'�[J! from��to�—tt. yards � bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS - �
�� REMARKS,SOURCE OF DATA,DIFFICULI'IES IN SEALING 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.
Uon Stodola �li Drillin� CA, Inc, 27172
Contractor Business ame I' License or Registration No.
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d ese �ve igna(urr Date
LOCAL COPY H G..G.LJ�L� �f'�i.-� . .'��� ._���-..,...,�.
Name o/Person Sealing Well or Boring .