HomeMy WebLinkAboutWell info wEll OR BORiNG LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I 1 ����+� �
ry WELL AND BORING SEALING RECORD Me��e9o"a u�;q„e we��No. �H—'��` 1
Coun Name r —
��n a e i n Minnesota Statu/es,Chapter 103/ or W-series No. � I
P M1.ww GeM�X�rot krrown) � _J
Townshlp Name Townsh�p No. Range No. Section No. Fractwn�sm.-►Ig.) Date Seated Date Well or Boring Constructetl
Qrono 117 23 20 ,�r��"�y �; � 9-18-01
Numencal S p�t,�A�O�ss or Flre Number and City of Well or Bonng Location
2773 � Point Rd� W&j�ZIIt8i kiN 553I1 DepthBeforeSeahng 72 fl OrigmalDepth n
Show exact location of N•ell or bonng Sketch map of well or bonng AOUIFEH(S) STATIC WATER LEVEL�
m section grid with"X". locanon, showing property Single Ayuder � MulOaquiter -��
lines,roads,and bwltl�ngs.
N WFLUBORING ❑ Measured �samated
_ _ tj Water Supply Well ❑Monit Well L�
t ❑ Env.Bore Hole ❑Olher _ _ v tt �elow ❑ above land suAace
W --�- -i-- -i-- --i— E 1 � . � CASING TYPE(S)
� � � �
� � � �
=� -�-- --�- -i-- --�- � - * � �Steel ❑Plastic ❑Tile ❑Other
, }1 mik
'_L' _J__ _�__ __i__ � . _ CiAS�I'I(3�5)
��� �`���' ��` Diameter Depth Set m oversize hole? Annular space initially grouted?
S ��,�""" ,,_,/
�r mi�e� 2 in.irom� to� ft. ❑ Yes �lo ❑ �es ❑ No ld Unknown
7`
P+1Pc.ZiI1�W�11G'T1 �l"j.C&..40I1 in.irom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
P�operty own s madinQ address if different than well IocaGon aadress indicated above. in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
2773 �`�F�J�I2t ROSt� SCREEWOPEN MOLE
W$yzata, Mt�t 55311 68 72
Screen from to ft. Open Hole irom to R.
OBSTRUCTONS
�181118 r.1.L4'Ei Er icksoii ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �y No Obsiruction
(�
Well owners meiling adOress if dilferent than properry owner's atlCress indicated above. Type of Obstructions(Describe) -
� Obstructions removed? ❑Yes ❑ No Describe
2773 Casco Foint PaCt PUMP
" Wa�F�ata, MN 55311 .tet
; Tvve
OEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
N rat krawn,indicete estimeted fortnatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE:
�Jo Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforetion/Removal
in.from to R. ❑ Pertoreted ❑ Removed
- in.from to ft. ❑ Pertorated ❑ Removed
Type of peAoretor
❑ Ome�
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
GroutingMaterial ��gt �'+Q�eAt from d to 7L fl. yards 1 begs
irom to tt. yards bags
from to ft. yards bags
from to__ ft. yards begs
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS ���Q�
Other unsealed and unused wetl or boring on property? ❑Yes ❑No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in eccordence with Minnesofa Rules,Chapter 4725. The information conteined in Mis report is
true to the best of my knowledge.
SCevehs DriZling & En�3ronenzent�2 Services $6654
Confrador Business Name License w Reyishatbn fvo.
. , ``�.-.,`� �. -��.---.---_ 9-19-U1
aumorized Represenrafive signeture Dare
Richard Stev��.s
H A ����� Name ol Person Seelinp Wep a Bonng
LOCAL CpPY i