HomeMy WebLinkAbout1993 well & boring sealing record Minnesota Well and Boring 2 8 8 3 9
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
co���v Name WELL AND BCSRING SEALING RECORD Mi��esoca u�iq�e No.
� F._'—__� Minnesota Statutes.Chapter 103/ or W-series No.
jjp�gpi7 �Leave blank it noi knownl
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Township Name Township No. Range No. SecUon No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
�A ��� � � 4 4 �� � �� � �,y f or Boring Constructed
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Numencal Streel Address or Fire Number and City of Well or Boring Location {�' t,
323S C+�sco Circle � �rp Cii� SJJs� Depth Before Seahng '''"� ft Original Dep�h "'� ft �
Show exact location oi wetl or bonng Sketch map o(well or boring Static Water Level Accurate
in section gnd with�X loca�ion.showing property lines.
roads.and buildings. ❑Approximate
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-,- - - - - -,- >> 7�
�1.� Single Aquifer ❑Mulhaqwfer fL ' ` below above land surface
i i i i 7 �.��
_i_ _�_ _i_ _i_ CASING TYPE
W i i i i E '�
� � � �
-r -�- -r- -r .'
� � � � �n mi�e Steel ❑Plastic ❑Tile ❑Other
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i_ _ i_ _i _ _i .
Screen from `��'`'� to —�+� ft. Open Hole from to fl.
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�--i mi�e—� -��� �� � OBSTRUCTION/DEBRIS/FILL
PR�7p ER Y NER'S NAME �i3Obsiruction ❑Debris ❑Fill
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/ Type of debris/obstruction �'� �� �� � ' F' �^' �'V " �-�
Maihng Address if different than property address indicated above. ��
Obsiruction/Debris/Fill removed? Yes ❑No
PUMP
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❑Removed ' Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depih Set in oversize hole? Annular space initially grouted?
If not known,indicate es6mated tormation log from nearby well or boring.
�� O � �in.irom �' to �"�- fl. ❑Yes �No ❑Yes ❑No ❑Unknown
in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exisis
f
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to fl. ❑Perforated ❑Removed
in.f�om to ft. ❑Perforated ❑Removed
Type of perforator
❑O�her
GROUTING MATERIAL
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Grouting material ti��'----' l.'� ��' from �-� to ��'�'� ft. yards �bags
irom to fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
irom to fl. yards bags
C+Sro�ited 2" vell 66' deep
� � C�it from to fl. yards bags
N � L�iItVliiLe UNSEALED WELLS AND BORINGS
f �
2 � �$����g a{ �t �jt ��) Other unsealed well or boring on property? ❑Yes No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATI N
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation contained in this report is
true to the best of my knowledge.
Dcm Stcx3ola Well. DriIl3x�g Cc�., Iz�. 27I72
Contractor Business Name License or Registration No.
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A-L�n�d Representative Signature Date
`°�r'`���Y " 2 8 8 3 9 �' �
Name ol Person Sealing Well oi Boring
HE-01434-01 �