HomeMy WebLinkAbout2002 Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ���/�^�� �
WELL OR BORING LOCAT�ON I
County Name WELL AND BORING SEALING RECORD Sealing No. �H L �_
Minnesota Unique Well No. i- — — �
�;� M�nnesota Stalutes,Chapter 1031 or W-series No.
,?1 Tt�!�)�.i T �,e,�,d�x n�a k�.,�� --
Township Name Township No. Range No Section No. Fraction�sm.-►Ig.) Date Sealed Date Well or Boring Constructed
t�rc�n� I17 23 ?� �1-0£���. � %�,�,' J�.
Numencal Street Address or Fire Number and City of Well or Bonng Location �, � ,
�. r� i/ `g �
�-� �1�� �.c`r'..��3 4.�� � j�rn�n DepthBeforeSealing_r'�` ___tt. OnginalDepth _ ,_�r..t% fl
Show exact location of v.�ell or bonng Sketch map of well oi boring AOUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing prpperty mgle Ayuifer � Multiaqwfer
lines,roads,and bwldi�gs.
N WELUBORING �Measured ❑ EsUmated
�
� -
� � � � "'����� �`Water Supply Well ❑Monrt.Well
-�- -;-- --;-- —�
-- �� , � � ^"t �,"
,*:r � .,� ❑ Env.Bore Hole ❑Olher __ _ H. �below ❑ above land suriace
yy —�- - — - -- --i— E . . ..__...._._.... . � CASING TYPE(S)
� �
� � �
� � � � �
� � �
� � � �
. —�- -�-- -i-- —�-- � � �teel � Plastic �Tile � Other
�
� � � � }4mile � � �
� � � � � _ �._.___.�. CASING(S)
-�-- -�-- -�-- --�--
Diameter Depth Set in oversae hole� Annular space initially grouted?
S """111��� � ,�, i y .� ` ' �
�t,—r mi�e—q. � in from �� to t"'�r'� tt. ❑ yes No ❑ Yes ❑No ❑ Unknown
I I
PROPERTY OWNER'S NAME in.from to ft ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
� /
PropeRy owner's mailing�address if diflerent than weil lowfion atldress intlicate0 above in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
���c ��&£y Fy� SCREEWOPENNOLE
y ) s x I
) t L Jtti
'.�_'�(3 e t] p�'$1��,�� �`�°!T rj 5 3 Y�} . - Screen from �"�'7 to �� ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No ObsVuction
Well ownei s meilin address if diBerent than r owner's aetlress mdicated above. �� " �� � ��
9 P�M Type of Obstroctions(Describe) � �d�!�����- Js���/� t �����/��'1�'
Obstructions removed? [�l'es ❑ No Describe
PUMP
TYPQ 'f j.:? 1�'ll;i?)�-;%
GEOLO(iICAL MATERIAL COLOR MARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formatbn log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space 6cists
; ��' ❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from ro ft. ❑ PeAorated ❑ Removed
in.}rom to ft. ❑ Pertorated ❑ Removed
Type of periorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.)
r-, t _,,.. �
A� � . ;
Grouting Material L'��� '-� ��r` �frdm '�-�� to� ft. yards � � bags
from to ft. yards bags
from to ft. yards bags
from to— ft. yards bags
REMARKS,SOURCE Of DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
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 Fules,Chapter 4725. The information co�tained in Mis report is �
true to the best of my knowledge.
�.c�r� °St��3�I;.� i�e1�. �rillin;; C�, , Inc. 2717�
Contracror Business Name . � License or Regishatlon I'ro.
��� �'�.. f:
� ! � ,
Authorized Represenfative Signature Dafe
H ������ Name o!Persar Sealiny Well or Bonng
LOCAL COPY