HomeMy WebLinkAbout1995 Well & Boring Sealing Record Minnesota Well and Boring �� �
WELL OR BOR�NG LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o„�,,�,ame WELL AND BORING SEALING RECORD^^���eso�a u��q�e No.
fi Mmnesota Sfatutes.Chapter 703/ or W-senes No.
ILeave Dlank il nol knownl
T .ship Name Township No Range No Sechon No Fracbon(sm. I � Da�e.Seale ' ..� Approximate Date Well
,_ j i� t. �-•' /% . i or Bonng Construcled
�-; -,� 7 J ��,���,4 �, , � J � ; �
Numencal Sireet Address or Fire Numbei and Gty, Well or Bonng Lcealion �, �
" F� Depth Before Seal�ng �%�"�'� fl. Onginal Depih ft.
C.:.t/ . 7" r�
Show exact Iceatan of well or bonng Sketch map ot well or bonng Stalic Water Level Q�Accurete
�n section gnd wdh��X" loca6on.showing property lines.
roads.and bwldings. ❑Approximate
N �
� I
� � �Smgle Aquder ❑Multiaqurfer ' '� fl. below above land suAace
i
_�_ - -i- � CASING TYPE •
W -- -� E
� -� r i � ,�v.Steel ❑Plashc ❑Tile ❑Other
mr�e
i i
i i i � � �1 C `7
S Screen irom to ft Open Hole from�-= lo��� '0��� tl
� �'"'k� OBSTRUCTION/DEBRIS/FILL
❑Obstruc�ion �❑Debns ❑FII
PROPEA'fk OWNER'S N
Type of debns/obsiruchon
Mailing Addre ddferent ihan property address indicaled above
ObstrucLon/Debns/Fill removed7 ❑Yes ❑No
PUMP
Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �
FORMATION
Diameter Depth Se�m oversize hole? Annular space irntially grouted�
tf not known,indicale esUmated formahon log irom nearby well or bormg. .,,....,.
/ 1 a
in.irom r "' to�-�- � ;- ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to fl. ❑Ves ❑No ❑Yes ❑No ❑Unknown -
in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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 fl. ❑PeAorated ❑Removed
in.irom ro fl. ❑PeAorated ❑Removed
Type of peAorator
❑Other
GROUTING MATERIAL
�...�}��, � � � �
Groufingmaterial "" �`r'l.�C/`�� irom ' � to t/ ft. yards bags
from to fl. yartls bags
REMARKS.SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑Yes �"No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
J�� � O ��� This well o�boring was sealed in accordance with Minnesota Rules,Chapter 4725 The inbrma6on contained in Ihis repon is
Irue to iheb'est of my kn�ledge. ,� ,.
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ConhactorBusrness Name f L�cense or Registrafron�No.
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�dr, '/ . /"_..'J.
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Aulhonze � ep`r`esentative Signafure � f�� � Date
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��� F t r'�..I f /, ., �"/.r'�-Y�G's•t_--..
��f���Wj n Name o�Person Sealrng Well o�Bonng
HE-01434�0�