HomeMy WebLinkAbout2014- Well & Boring Sealing record � MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring „$ "� +Ff'# �' � �
WELL OR BORING LOCATION Sealing No. H .� ,.!., ��,.� �
��� County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 0�W-series No.
Ii�nr��,in
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
�ror�o 117 ?3 20 �� 9W �s? Z-12-14
GPS LOCATION- decimal degrees(to four decimal places)
Depth Before Sealing_ �___ ft. Original Depth ft.
Latitude __ Longitude
AQUIFER(S) STATIC WATER LEVEL
��� Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer
t WELUBORING .r�vleasured ❑Estimated Date Measured ��12��
3225 CascopC'rl, �rono �
; I,�'�Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or boring �-�� ' '`
in section grid with"X:' location,showing properry ��Env.Bore Hole �_Other __ _� -i ft [�below �.�]above land surface
lines,roads,and buildings.
nl } CASING TYPE(S)
�T ?'-
.: _'___ ' ` __'_ �
� i i i i I�s�eei f�Piast�c L]T�ie [�ome� '
:' --�--- --�------�-----`-- ELLHEAD COMPLETION
: W ; ; : � ET � "" -
,
,
, . . ; �".' `� �
. , 1 r r f M�i } Outside: i _I At Grade Inside: �Basement Offset
_ ___ __ ___ __ __ __ __ � _,Well House �
�' --'--- --1------;-- ---'-- ,_, itless A p dUnit ... uned Buriledit
� P da te B �J
� ❑Well Pit f�
S
Other
�� — —
�i Mile� ❑Other_
PROP Y2 OWNER'SaN.A,ME/COMPANY NAME CASING(S)
���i'�� �+ >��nS Dia(�qeter n Depthy.G Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different ihan well location address indicated above G E f �V
__. in.from to ft �'Yes �No ❑Yes ❑No (J Unknown
�1��1� Ct� a[.� � in.from to ft. '�,�j Yes '�J No ❑Yes ❑No ❑Unknown -
tio�kins, 1�N 55343 --
_in.from to ft. I---�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 _�" __to `"" _ft. Open Hole from to ft.
OBSTRUCTIONS
}�Rods/Drop Pipe �. I Check Valve(s) [_J Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) ur�`L} ��� � C}�Lj.?1C�eL _____
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. 7��,
Type�t L�.+�
.j I y�`Removed ❑Not Present [�1 Other �
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exisis I]Annular Space Grouted with Tremie Pipe [.;Casing Perforation/Removal
' . .___in.from to ft. ❑Perforated '�]Removed "
: in.from___ _____ to ft L�Pertorated i ]Removed �'�
= Type of Perforator -
VARIANCE
Was a variance granted from the MDH for this well? [!Yes �'No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material�at �.'�,('�� Q from�.__ to___{S� 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 CONTRACTOR CERTIFICATION
This weil 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.
non Stoc�vl� �+�ell nrillin; Co,. Inc. lf��?1
Licensee Business ame . '� License or Regist�ation No.
� -:;�" ��"�_ Z—I�—IG
� _— % - ,
, ,.:. .aM .
, �— __ _— -- - ;
�� e 'd Representative Signatur Certilied Rep.No. Date
` LOCAL COPY H �j TiR1 SC�CLIPC
�;�(„3��o Name of Person Sealing Well or Boring
�; HE-01434-14 IC#140-0423 5��3q
,
',,._:..��,....,:...... .........�. . ....:.. ..:...._... ..,... . .. ._ ... . _.... -":.,, . . .... ..... _��.....__..... ._ .._,.._..._._n......._,�.._,_.�_. ...._.-.�..,.n...,.....,.�._._.�__za_�._,.a..._.._._ _,_._�_..., . ........_:..A,_...._> ....;:..