HomeMy WebLinkAbout2014 Well & Boring sealing record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Borin �7 �� "
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. 9 H ��'�� �� �- _
County Name Minnesota Unique Well No.
Minnesota Statutes, Chapter f037 or W-series No.
`�ez�r�e�jn �e�e e�z�k„�o,k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed "
�Cc�no 11? 23 2Q �F'�fi�;�,...,� U Sr=� I�-�
GPS LOCATION– decimal degrees(to four decimai places) /�' �
" � Depth 8etae Sealing f,i/_ ft. Original Depth,__..,_. ft. .V,
atitu e________ ongitude
-- —
�� �� UIFER(S) STATIC WATER LEVEL '
/j� m rica�et Address or Fire Number and City of Well or Boring Location ,'Single Aquifer �]Multiaquifer � � �,r�
U ?Jt; rr�g0 40e� �r�� WF�UBORING Measured ;.j Estimated DateMeasured __�1��� r.�'"1Y
j� pp y Manit.Well (�i� � �/
Show exact location of well or boring ..� �� Sketch map of well or boring � Env.Bore Hole i_� �` ^� x�
ater- u I Well ,_.
in section grid with"X" location,showing pr erty - ..I Other_ ,__ __ ____ ._ ft. �IV below ...;above land surface �.
, nes sq�{is,and bu mgs.
N - -- �-__-� �_..�..,,-�. CASINGTYPE(S)
'� '--- � L .--
, , � 1� [�teel , �Plastic , I Tile '�...i Other_..._-- — --_. _._.---- .`
` ''--- ` �-- •�� WELLHEAD COMPLETION � � �
.. � � � � ...__„
. W ; ; ; : ET
�` __;___ __,___ __�_ __�__ Outside: _.'�,Well House ��At Grade Inside: �Basement Offset �
� ' ' ' ' t - d � eil Pd
, , , , '/M'e LI Pitless AdaptedUnit � une .__
�
: I._,g . 'W �:
--,--- --,-- --�-- --:- l --.,..__.__..�
���Buried
S ❑Well Pit
F-1 Mile� ❑Other �..�Other _ _
PR(Q�PEp7 TY OWNE(g�'S NAME'CO NY NAME CASING(S)
`-�O1�Q� `�U-S�� ��g Diameter � � Depth f Set in oversize hole? Annular space initially grouted?
Properry owner's mailing address if different than well location address indicated above � �p �j -
�,�in.from to�� / ft. [j Yes �No ❑Yes ❑No ❑Unknown
216 [��ter �t
��l.g.l��r� i�3 55331 in.from_ to ft. ���Yes �_.No [�Yes []No ❑Unknown
j _in.from _ to _ft. n�Na � ��-
❑Yes �,,, ;J Yes ❑No '�,Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
r �
Well owner's mailing address if differem ihan property owners address indicated above Screen from t G. / t0__���___ft. Open Hole from_ to ft.
t
� OBSTRUCTIONS
I �Rods/Drop Pipe �_I Check Vaive(s) _,'Debris �]Fill �No Obstruction
' Type of Obstructions(Describe)_.,,.___
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? ❑Yes �._No Describe -
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
dCl L C Q �3 TYPe ---. __-- -
, � '�Removed �Not Present ❑Other �-
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,Ofl CASING AND BORE HOLE:
j�No Annular Space Exists '.�-'Annular Space Grouted with Tremie Pipe �]Casing Perforation/Removal
�i in.from,,.._ to ft. I.�,]Perforated ` ��Removed
in.from, to _ _ft ���]Perforated [ J Removed
Type of Perforator______
VARIANCE
Was a variance granted from ihe MDH for this well? [_]Yes No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
; ' �� , r
�� Grouting Material N`/7� ���'vI irom_ to �� ft.__.__ yards � bags
' from to ft. yards bags ?
a __________ from____ to _. , ft. __ _ yards______ bags
� OTHER WELLS AND BORINGS
1
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? `�i Yes f�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 knawledge.
�ln � Y t GQ
�censee usines––s 10`e - � � � *{,�� License or Registration No.
, ,,1� �" '`� Ff� ', �'��"14 4
__-
_ - __ - ---- - — .
Certified Represent 've Signatur� Certilied Rep.No. Date
Jim Antonson
' LOCAL COPY H 3 2 4 7�4
- -- --. _------
Name ol Person Sealing Well or Boring
HE-01434-14 IC#740-0423 Sn3R
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