HomeMy WebLinkAbout02/24/1998- Well & Boring Sealing Record MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring � ������� '.
WELL OR BORING LOCA710N Sealing No. H
�o���y Name — WELL AND BORING SEALING RECORD M,��esota��;q�e No �- -- �
Minnesota Statutes,Chapter 1031 or W-senes No.
ILeave blank i�not knownl
Township Nam Township No. Range No. Sec6on No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
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Numerical Street Address or Fre Number and City ot Well or Boring Location � ,
Depth Before Sealing ���-~ 8. Original Depih ��� fl.
Show exact location of well or boring Sketch map of well or boring A UIFEH(S) STATIC WATER LEVEL
in section grid with"X". --- -���,����.�.,location, �showing property Single Aqwfer � Multiaquifer '
lines,roads,anQ buildings.
N � � WEWBORING �Measuretl ❑ Estimated
i �
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� � � �Water Supply Well ❑Monit.Well •
--r- -� �-- -�-- r i
� ' ' � Env.Bore Hole ❑Other / t^ ft. below
� � � > ❑ — � ❑ above land surface
y;
yy -- - - -- -�-- --'-- E o CASING TYPE(S)
� �
� � � ...
�
� � � �
-�-- -�-- --i-- --�-- - . � : Steel � Plastic �Tile �Other _
�mde . _ _ . . .
' ' ' ' � �. � CASING
--�- -�-- --�-- --�--
� Diameter Depth , Set in oversize hole? Annualar space in�tially grouted?
��i mna��, ��� !:��—��LL� � �/in.from !�..� to C � tt. ❑ ves `�j No ❑ ves ❑ No ❑ unknown
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PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
Property owner's mailing address if diNerent than well location address indicated above. in.trom to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
/ � �/ �
Screen from �/� ro�.,�._ tt. Open Hole irom to R.
OBSTRUCTIONS
WELL OwNER'S NAME Rods/Dro Pi e
p p ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
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Well owner's mailing address if diHerent than property owner's address indicated above. TypB Of ObSt�uctions(Desc�ibe) �l��✓!� '� ��-�%�T� � /""< ��/ fj'�-�//i f
Obstructions removed? �Yes ❑ No Describe
PUMP
Type ._f;:r�.�/�i�i;__ �. / F! /�%� i� .. . , -
GEOLOGtCAI MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
tl not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exits
? 1
_., , ❑ Annular space grouted with tremie pipe �
�j ❑ Casing Pertoration/Removal
in.trom ro fl. ❑ Pertorated ❑ Removed
in.irom to ri. ❑ PeAorated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
�� � ,
Grouting Matenal� "�"�' ��'f��'{Trom �-= to�_ ft. yards � bags
from to R. 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�f No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well oi boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
, true to the best of my knowledge.
Don Stodvla �1eI1 Drilling Co. , Inc. 27172
(�. Confractor Business Name License or Regisfratlon l70.
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Authonzed Representative Signature Date
H 13 4 916 Name of Person Sealing Well or Boring
LOCALCOPY
HE-01434-03 2/97 R