HomeMy WebLinkAbout2006 well & boring sealing record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I
Counry Name
WELL AND BORING SEALING RECORD M nnle ota Unique Well No.
�nne� in Minnesota Sfatutes,Chapter 1031 or W-series No.
(Leave 04nk ii�krwwn)
Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed
t�rono � 7 23 20 3-tj(� �,. �,. ,. �
GPS ��� degrees minutes seconds ���� /
LOCATION: Depth Before Sealing---���+¢-t ft. Onginal Depth tt.
Longitude degrees minutes seconds pQU1FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaqu'rfer
C 1 Or S3 1 WELUBORING �(Aeasured ❑Estimated
/'
�Water Supply Well ❑Mond.Well
Show exact location of well or boring � Sketch map of well or boring
in section grid with'X" N ._.�---focation,showing property ❑Env.Bore Hole ❑Other ft. �Q below ❑above land suAace
lines,roads,and buildings. � �
N CASING TYPE(S)
- - - - - -- -i--
�� Steel ❑Plastic ❑Tile ❑Other
W --�- - - - — --i-- E �� WELLHEAD COMPLETION
� � � � __
• Outside: ❑Well House Inside: ❑Basement Offset
—�- ---- -;-- -i--
1��b ❑Pitless AdaptedUnit ❑Well Pit
--;- -�-- -�-- --i— I .
1 �Well Pit ❑Buried
S
�—�'"M�. ;. ,+,.<:,. '..f. �7� ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameter Depth � Set in oversize hole? Annular space initlally grouled?
P in � re�t than well location address indicated above �� �
� in.f�om� t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown
C�OSCBVC' I?C�C�t3k3ri W� $�!X
4367 Shorelicze nC in.from to ft. ❑ves ❑No ❑ves ❑No ❑Ummown
��C�T]� P$C�E� � ��}3�1 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
W L N MPANY NAME SCREEWOPEN HOLE
/ �
���.'.�• '/��
Well owner's mailing address if ditterent than property owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft.
OBSTRUCTIONS
�;Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)�At1L<� f.�p` g V.< J
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Y2S ❑ NO Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
TYPe `-} ��" i_"L'!�'1�]
�' ''�" `� �Removed ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
[�lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PeAoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonRe=50 Ibs.)
/� /��� i �,+�� �
Grouting Material!�'Gq T (,.:.[/��m�to�ft. yards � bags
from to R. yards bags
from to R. 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 well 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.
T�i �t13dc�I� �e13 ntll.ir�CD,. Inc. 2717�
Contracror Business Name . License or Registra6on No.
_ �- /i ,a C�
epr'e ative i ture Date
,r'' �
LOCAL COPY H �"7�'7�./O �~ t _ " �t.., i �v ..�,d`r...✓
Name ol Person Sealing Well or Boring
, 1