HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �g 5 7 0 9
County Name WELL AND BORING SEALING RECORD Minnlego a�Unique Well No.
��N$p;� Minnesota Statutes,Chapter 103/ or W-series No.
��ea�e oia�k a�o�k�ow��
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
BON 11� "�3� �9 N'` J/� � !U
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GPS Latitude_ _ degrees minutes seconds Depth Before Sealing ��� ft. Original Depth ft. �
- LOCATION: Longitude _ degrees __ minutes__ seconds AQ IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑MWtiaquifer
• �.d• �j,"Qn� asi�• ��WG Measured []Estimated Date Measured� �' � �
• upply Well ❑Monit.Well �
Show exact location of well or boring Sketch map of well or boring i -��Env.Bore Hole Other � '__fl. below
in section grid with"X:' �.--; location howing pro erty �- ❑ � ❑above land surface
N lines,r s and b in s. CASING TYPE(S)
` --'--- -`-----`----'--
teel ❑Plastic ❑Tile ❑Other
� '"''----'--- ---`-----`-- WELLHEAD COMPLETION �
W ; ; ; ; ET _
�; __�_____,___ __;_____r__ Outside: ❑Well House �]At Grade Inside: ❑Basement Offset �'
_� , , , � nniie PitlessAdapter/Unit �Buried ❑Well Pit
h � •
� --,--- --,--- --.-- ---:- 1
❑Well Pit ❑Buried
S ❑Other
�1 Mile—� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Dia.�mfeter /� � Depth � Set in oversize hole? Annular space initially grouted? -
Property owner's mail t Ih tion address indicated above �! ��in.from i✓ to���ft. ❑Yes �No ❑Yes ❑No ❑Unknown ���`
15a050 23 =� ��� i� in.from to ft. ❑Yes �.]No ❑Yes ❑No ❑Unknown
Plyaouth, l�N.. 55447
in.from to ft. ❑Yes [�No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
: � �
x Well owner's mailing address if different than property owner's address indicated above Scfeen frOm���to��__ft. Open Hole ffom to ft.
OBSTRUCTIONS -
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction
Type of Obstructions(Describe)
2 HARDNESS OR Obsiructions removed?
GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Yes ❑No Describe
If not known,indicate estimated formation log from nearby well or boring. PUMP
Type
❑Removed �Not Present ❑Other
METHOD USEO TO SEAL ANNULAR SPACE BETWEEN 2 CAStNGS,OR CASING AND BORE HOLE:
� No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. []Perforated ❑Removed
in.from to R [)Perforated ❑Removed
Type of Perforator
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material �+�/+�� ���.��.,6(om�_ to�� ftr yards �' bags
trom to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING � Other unsealed and unused well or boring on property? ❑Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or 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 STOD�LI► WEI.I. t�ittT.r.INO C0.-, �I�I�. ,an, ,
L�censee Business Name �....._ '.„_. y„-. L�cense or Reg� r �n o.
/
�-- � 558 —/S'- /O'
C �fi reS ntative Signature � Certified Rep.No. Date
� . �...,..,
LOCAL COPY H �}(��O 4 Name ol Person Sealing Well or Boring r
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HE-01434-11 IC#140-0423 - 2ioaa