HomeMy WebLinkAbout12/29/1995-Well and Boring Sealing Record , �
�Su� (�y,S�� /�� „�(( Minnesota Well and 8oring
WELL OR BORING LOCATIJi�
� MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD^^���eso�a u��Q�e No.
�� � Minnesota Statutes.Chaptei 703/ or W-senes No.
1Leave blank il nol knownl
Township Name Township No Aange No SecUon No Fractwn�sm. �Ig.� Date Sealed Approximate Dale Well
�-. •-� or Banng Cons�rucled
Oror�o II7 23 2J '14 ��, '14 � - - �� , v
Numencal Sireel Address or F�re Number and City of Well or Bonng location ;/ �t
Depth Before Sealing �`, ft. Original Deplh ` � ft.
L�on Park Ltfl BIk 6 25RX Casco Pt
Show exact Iocalan ol well or bonng Sketch map of well or boring Static Water Level �Accurate
m section gnd wdh�X- IocaUon.showing property hnes.
�s � roads.and buildings. ❑Approximate
N
i � i
-- -�- --- -- �- ; :/�
��Single Aquifer ❑Multiaquder fl. below above land surlace
i i � i ;
_i_ -�- -i_ CASING TVPE
W E � ..
� � � � �°! �^�^-._._...
-r -,- -r- -
i i �Steel ❑Plashc ❑Tile ❑Other
m�k �,i , ;!��>
-- - � - � ' .. _
�- -i - -i _. . ,f
S Screen from �� lo ft Open Hole trom lo ft.
N--t m��e—� � OBSTRUCTION/DEBRIS/FILL
�^ Obstruction ❑Debns ❑Fill
PROPERTV OWNER'S NAME
1�'il�e �rC3�1SOfl �Z S� fi ,
Type ol debns/obsiruction
Maihng Address il ddferenl than propeAy address indicated above
5217 8Gth Ave l� Obsiruction/Debris/Fill removed� �Yes ❑Na
PUMP
Broo3clyn Park, 55443
�Removed ❑Not Presem ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO •
FORMATION
Diameter Depih Set in oversrze hole? Annular sp2ce�nAially grou�ed7
If not known,mdicale estimated formation log from nearby well or bonnq. � -
�� -� , _ ��� L,. f � �/��in.from � to -" �-� ft. ❑Yes Q No ❑Yes ❑No ❑Unknown
..�%i. .- . (
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
1�No Annular Space Exists
❑Annular space grouted with iremie pipe
❑Casing Per(oralion/Removal
m.from to fl. ❑Perforated ❑Removed
f
in.irom to fl. ❑PeAorated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
,i; �'" ' + i
Grouting materlal � � - -� "trom �- to =�fl- yards � bags
from to ft yards bags
REMARKS,SOURCE OF DATA,DIFFICUITIES IN SEALING
from to ft yards bags
trom to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or bonng on property? ❑Yes �},No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
J A N j O 1996 This well or boring was sealed m accordance with Mmnesota Rules,Chapter 4725 The information contained in this repoA is
' irue to the best of my knowledge.
?k�n Stodo3.a tdell DrzlZir�,. Co., It�ic. 27172
Confractor Busmess Na e !%� L�cense or Reg�sVaGon No.
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.,�-'�';�/f� � ,�' / .� y� � ,�
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o d RepresenfaUve Signature ' Dafe
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{.� �] % � •'�. ��: ,� .. -� ' a`
����� ■■ �� ± �7 Name o!Person Seabng Well or Bonng
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