HomeMy WebLinkAboutWell info� _ � �
MINNESOTA DEPARTMENT OF HFALTH Minnesota Weil and Boring ������ �
WELL OR BORING LOCATION Sealing No. �H
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
I�tens�epir� M�nnesota Statutes,Chaptei 1031 o�Wq�ries No. �-- — J
- Township Name Township No. Range No. Section No. Fraction(sm.-i Ig.) Date Seated Date Well or Bonrg Constructed
'� r
Numencal Street Adtlress or Fire Number and Gry of Well or Boring�ocation
.-��� / ,r� i"� a
Depth Before Seahng_��",l? ___ft Oriqinai Depth _��i h
Show ezact locahon of v.�ell or bonng Sketch map of well or bor�ng AOUIFER(S) STATIC WATER LEVEL
in section grid with"X". - IocaLon, showmg property ingle Aywfer ❑ Muttiaquder
� Imes,roads.and buildings. �,`
N � , � `� � �. WELUBORING y�measured ❑ Estimated
� � � � � �� � ' ' � �Water Supply Well ❑Monit.Well
-�- -i-- --�— --� , �
Y �t ❑ Env.Bore Hole ❑Other _ _�f� }�, [�elow ❑ above land surtace
W -�- -i-- -i-- —i— E � t"+`� CASINGTYPE(S)
� � , � _-
� �
.� -;-- -;-- --;-- --i- � 1G�Steel � Plasfic �Tile �Other
� � Ylmile T -
—�- --�- -�-- --�— � �...._. CASING(S)
Diameter Depth t Set m oversize hole9 Annular space initially grouted?
S r♦
�r mi�e� __� in.from_�_ to_��,,.nft. ❑ Yes �/No ❑ Yes ❑ No ❑ Unknown
T
PROPERTV OWNER'S NAME in.irom to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
'r , +
P�operty owner's maJing d ss il diHerent than well location adtlress indicaled a ove. in.from to ft. ❑ Yes ❑ NO ❑ �e5 ❑ NO ❑ Unknown
J't�� P1O�i�$ AV� SCREEWOPENHOLE
�st�Tr / t S`; �
C���a�� �gt� J��{�y7 Screen from ��'-. to �ii1— tt Open Hole from to ft
OBSTRUCTIONS
WELL OWNER'S NAME � : _ � . -� Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction
�;'�:_. , �? '�.. � .. � ��. . ` '� .. . � ,ry ./
Well owner's mailing address d diflerent than property owner's address indicated above.� Type 0�Obslructions(Desc�ibe)��yb,(�'� ,���r� g �
Obstructions removed? es ❑ No Describe
PUMP
Type
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �lot Present ❑ Other
FORMATION
If rat known,indicate estimated lormation log from nearby well o�bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�.' �. �o Annular Space Exists
� r . ✓ • �
i m ❑Annular space grouted with tremie pipe
i ❑Casing Perforation/Removal
in.from to ft. ❑ PeAorated ❑ Removed
in.trom to fl. ❑ Perforated ❑ Removed
Type of pertorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
, �
C:�
Grouting Matenal ry ��? � �� to�� tt. yards bags
from to R. yards bags
from to tt. yards bags
from to__ R. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes o How many?
� UCENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
trua to the best of my knowledge.
i3on Stodola Well �ril.lin;; Co, , I�c. 27172
Contracror Business Name License or Registration fro.
_.,
, f �/
.T..-..^"'"~� .
�f' _.� ' �'. `J'' .r�r,._ �� % �
/i.F'`%.., , �
A�i Y ed` presenfative Signafure �Defe
.. �; , � �f��,..,�,,,
������ Name ol Person Sealing Well qi Bonng
LOCALCOPY H