HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL AND BORING SEALING RECORD Sealing No. H 112 9 8 2
County Name Minnesota Unique No.
��� � Minnesota Statutes,Chapter f031 or W-series No.
� (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.-s IgJ Date Sealed Date Well or Boring Constructed
C3noo�o 117 23 20 2�-4QI7� v 9�
N�um�7erical Street Address or Fire Number and City of Well or Boring Location � �
IW 75 C�3C0 � Rd� ��11� Depth Before Sealing ��� ft. Original Depth ` �� ft.
Show exact location of well or boring Sketch map of well or boring A�UIFER(S) STATIC WATER LEVEL
in section grid with"X". - location, showing property ingle Aquifer ❑ Multiaquifer
lines,roads,and buildings.
N WELL/BORING �Measured ❑ Estimated
/ /,
� � � � Water Supply Well ❑Monit.Well �
_Y_ _Y_ __,__ __l__ � , �/�
� � � � ,
� .� ❑ Env.Bore Hole ❑Other �,�ft. �elow ❑above land surface
� � � �
� I !� �'
� W —�- -�-- -,— --,-- E j ,� .. CASING TYPE(S) ..
� � : �
i i � • �
i � i i
C � '
-=r- -�-- --�-- ---I-- $teel ❑ Plastic ❑Tile ❑ Other
!6 mile
-�-- -�-- -�-- —�-- � �. CASING
� Diameter Depth � Set in oversize hole? Annualar space initially grouted?
�tt"" "�" ! Q
t mi�e� �� - �, in.from� to�S,L ft. ❑Yes �No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAME in.from ta ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown
Property owner's mailing address if different ihan well location address indicated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑ No ❑ Unknown
1��45 Iro�ood Crt SCREEN/OPEN HOLE
� rL�.l�.�� J�J`TV 93T-5050 Screen from�,ro� ft. Open Hole from to ft.
O BSTR UCTION/DE B R I S/FI LL
WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
A �//��� I ��
Well ownei's mailing address if diflerent than property owner's address indicated above. Type of Obstruction/Debris/Fill �/S.�.N�/t�� ! '� q" V��
Obstruction/Debris/Fill removed? [�Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log irom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� No Annular Space Exits
'`-�`-� � ''• � ❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
�
Grouting Material '� m � to�.��. ft. yards � bags
from to ft. yards bags
€
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unseUled well or boring on property? ❑ Yes � No
LICENSED OR REGISTERED CONTRACTOR CERT ICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
true to the best ot my knowledge.
�tm Stodola Well Drilii�� ce.; Znc. 27172_
Contractor Business Name License or Registration No.
------- �;�; r;
.afUth .'ed R 23en�ative Signature Date
�
�
, .; f
,., ; ti�1:`�".�,,
Name oi Person Sealin�Well or Bonng `�
LOCAL COPY H �. 1 � 9 8 2
HE-01434-02 10/95R