HomeMy WebLinkAbout2012- well & boring sealing record ` MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �O��} �C
� WELL OR BORING LOCATION Sealing No. H j, �,�
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Cha ter 1031 or W-series No.
�@IIYi���31 p ��ea�e e�a�k n�o�k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.—�Ig.) Date Sealed Date Well or Boring Constructed
h' Ozono 11? 23 20 �W �E�� E � �
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GPS Latitude ___ degrees minutes seconds Dep efore Sealing �_�__ft. Original Depih R ��:.
LOCATION: Longitude degrees minutes seconds '
AQ IFER ) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ` �Multiaquifer
��7 WELLiBORING �leasured ❑Estimated Date Measured_a��� ��_
3165 C.d$�.`Q C..irK.'1@ �rOt10�. �aa�• �yater-SupplyYsJell nMoniLWell /
Show exact location of well or boring Sketch map of well or boring � "�; .
_ in section grid with"X." ,�-�� location,showi pro(�erty Env.Bore Hole �� '�Other _ �__ft ��below , ';above land surface
N � , lines,roads,�builtlilos. CASING TYPE(S)
� i�._L,J" , -- �..._J._..� '
'� 'ySteel ❑Plastic ]T�I �[!Other __ ______ __
�� � � , � � �� ::
" --'-----`-- ---�-- ---�-- WELLHEAD COMPLETION �
= W ; ; : ; ET
' � � _�__ __ ;_ � utside _,�Well House ❑At Grade Inside: ❑Basement Offset
�
F'" o ' :
--- `' �
'h Miie � ��� ❑Buried ❑Well Pit
� �. �'� �itlessAdapter/Unit
\� � ❑Buried
' T S ' ' ., l4Y :]Well Pit
�1 Mile—� �/ �,/ ❑Other ❑Other
� PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
" Diameter � Depth � Set in oversize hole? Annular space initially grouted?
>� Property owner's mailing address i di eren than we location address indicated above 1�
�_in.from$ to���ft. ❑Yes '�lo ❑Yes ❑No ❑Unknown
64n7 Way zata BIYC�• in.irom _ to ft. ❑Yes J No ❑Yes ❑No ❑Unknown
M�.ls. ,. KN. 554Zb
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY N E SCREEN/OPEN HOLE �
. �
t Well owner�s mailing address it diNerent than propeny owner's address indicated above Screen irom__2,t��to��ft. Open Hole from to _ft.
� i
OBSTRUCTIONS �
���Flods/Drop Pipe ❑Check Valve(s) [Debris '��Fill ❑No Obstruction
Type of Obstructions(Describe) ��iC1iG �H_' � � �
GEOLOGICAL MATERIAL COLOH HARDNESS OR FROM TO Obstructions removed? ' Yes �]No Describe
FORMATION ---------
PUMP
If not known,indicate estimated formation log from nearby well or boring. Q
- .. . TYPe_�p ��
f�" � ��� emoved �_Not P sent ❑Other
�
r METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE:
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed c
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 �/��T�,L���IRom�_ to_��ft. yards� bags
from to ft. yards___ bags
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? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOA�CERTIFICATION � � � �
This well or boring was sealed in accordance with�Minnesota Rules,Chapter 4725.The iriformation contained in this report
is true to the best of my knowledge. � ��
Dt?N STODOLA WELL DRILI.ING CO. .. INC. Ib91
Licensee Business Nam � License or Registration No.
� 5.58 �-✓��i - f.,� .
�
- ---
Cer� ep e a i Sig e Certified F)ep.No. Date k
��rJ 1.7 r3 ���-, � ;��.�.,,, .�„ ..,-�,..a�--,...,
LOCALCOPY H L
Name of Person Sealing Well or Boring �
HE-01434-72 IC#140-0423 s/osR
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