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Home My WebLink AboutWell info WELL OR BOFiNG LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring j ��{�� Counry Name WELL AND BORING SEALING RECORD Minnlesota Unique Well No. I H— a-- Mmnesota Sratu�es.Chapte�1031 or W-series No. � I . `lt 1+..��,.�,,, �Leave Clenk H not krawn) _ _J Township Name ,.Townsh�p No. fiange No. Section No. Fr,� on,(sm.-i Ig.) Date Sealed� Date Well or Borirg Constructed l `f��/ r f --. I� �� > •= :. F3`' T n"% t .�`.. � �� Numencal Sireet Address or Fire Number and Gty of-yYVell or Bonng localion �� - '- � •�' � � :'�`� Depth Before Seahng � ' R. Onginal Depth h . - f 'f( ----�— Show exad IocaLon of N•ell or bonng / Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL in section gnd wrth"X". location, showing property �'Single Ayurfer � MWUaquiter lines,roads,and buildings. N WELL/BORING (i�Measured ❑ Esumated __ �__.: � � �Water Supply Well ❑Mona Weu � - - - -- -- -- - -- ' {� � ❑ Env Bore Hote ❑Other �fl. ❑below ❑ above land surface _ I I I ; W -r- -�-- -�- --�- E ...�_..___.._..,r-' CASING TYPE�S) --;-- -;-- --;-- —�-- � �yf [j Steel ❑ Plastic ❑T�le ❑ Other_ � � � }�mile � ;�/ --- --- -�-- - - � CASING(S) �`r � � Diameter Depth Set in oversize hoie9 Annular space initially grouted? �r mde�e ��-�-�^•^�'"�'� � �; m.Irom to JJ f"`I ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown I PROPERTV�OWNEA'SNAME,r -�_� m.from to ft ❑ Yes ❑No ❑ �es ❑No ❑ Unknown ' ," .e. [jr � , .. : �,,`r F Property owner s mailing ad ess i diflerent than well location address intlicated above. m.irom to � R. ❑ �es ❑No ❑ Yes ❑No ❑ UnknOwn � -/ " ' ,'',3 ��j�`1.,s'-t.-"�C.� _ .� , � � � , /� SCREEWOPEN NOLE l � '" Screen from � to �F�' ft. Open Hole irom to tt. OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction W811 owners mailing address if difleient than property owner's atldress indicated above. Type Of ObStruCliOns(D65Cfibe) Obstructions removed? ❑Yes ❑ No Describe PUMP f Type GEOLO(iICAL MATERIAL COLOR HARDNESS OF FROM TO Q�Removed ❑ Not Present ❑ Other FORMATION If rwt known,indicate estimated formatwn log hom nearby weli or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE: ❑No Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to tt. ❑ PeAorated ❑ Removed in.from to n. ❑ Perforated ❑ Removed Type of pertorator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag oi bentonite=50 Ibs.) � Grouting Material �'' from to � tl. yards bags from to tt. yards bags irom to tt. yards bags from to__ ft. yards bags REMARKS.SOURCE OF DATA,OIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes ��No How many? LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information co�tained in Mis report is true to t�e best of my knowledge. . . . _. %.C. . . Contracror Business Name f� License,w Registretion!'a. . �- X f�' � . �. AuMorized Representative Signature Dete i :,�e!L-E H ��A� Name o!Person Sealing Well or Bonng LOCAI COPY i MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �� WELL OR BORING LOCATION I -- WELL AND BORING SEALING RECORD sea�i�g No. �H_ Counry;Name Minnesota Unique Well No. r --- ! Minnesofa Sfatutes.Chapler 1031 or W-series Na L � . -.. f; ..,:f:i'�.`/� 0.eeve denk rc na krwwn� Township Name� :'�Township No. Range No Section No. Fract'pr�Ism.-i ig.) Date Sealec�+' Date Weu or Boring Constructed l �; � �, -� � �~ ' ;J' ��G. �! ',` (�. �� .. , �Numencal Street Adtlress o�Fire Number and Gry ot Well or Bor�ng Locahon '"] � ;%,� �` Depth Before Seal�ng� R Original Depth _ft Show exact location of v,•ell or boring �Sketch map ot well or boring ApUIFER(S) STATIC WATER LEVEL in section gnd wrth"X". locauon, showing property �Single Aywter � Multiaquder lines,roads,and buildings. N WELUBORING 0 Measured ❑ Esnmated _ �� + [�Water Supply Well ❑Monit.Well - � - --� �— � 7 � �;� : ❑ Env.Bore Hole ❑Other ___ _ tt. ❑beiow ❑ above land surface -�.1 ' ! . W -- - '�-' -� i-- E -. ' . CASING TYPE(S) � . � � � � , , . • v :,. � � � % -�-- -�-- --�— —i-- �, ��Steei ❑ Plastic ❑Ti�e ❑ Other }1 mile > -�-- -�- -�-- �-i-- � CASING(S) Diameter Depth Set in oversize hole9 Annular space initially grouted7 S =-! �t mi�e� in.from to� H. ❑ �es ❑No ❑ Ves �No ❑ Unknown - PROPERTY OWNEfi'S NAME in.irom to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown "/'' t _ Property�owner's ma��ng aAOress ii tliHerent ihan well locanon address intllcated above in.from to tt. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown k �� . ��i._ .� /f�,t . :- . SCREEWOPEN HOLE ; . q _- _ . . .. _� �.�� Screen from ro�'f R. Open Hole irom to fl. OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mei�ing address if dilferent than properry owner's address indicated aDova. Type ot Obs�fuCtions(DeSCrib@) Obstructions removed? ❑ Yes ❑ No Describe PUMP TYPQ ,'..r^� _.,.y. r.: �cK_r GEOLO(i1CAL MATERIAL COLOFi HARDNESS OF fROM TO �Removed ❑ Not Present ❑ Other FORMATION If rwt known,indicate estimated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BEIIUEEN 2 CASINGS,OR CASING AND BORE HOLE: ❑No Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casi�g Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.irom to R. ❑ Perforated ❑ Removed Type ot perforaror , ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ♦ , .�'� ,. ; , �� ` ..� �...,` .; Grouting Matenal �f��"�-��r� irem " to fl. yards ' bags trom to tt. yards bags from to tt. yards bags from to__ ft. yards bags � REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes [�`No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in Mis repoA is true to the best of my knowledge. - Contractor Business Name � License or Regisfrefion I'ro. ,'.-( . .�� ,�-, r '. . . �_- Autho�zed Representafive Signature ' � Defe .'�`�r' . � (��i� f A,�`�.-�i...� LOCALCOPY H 19 7�2 8 Name ol Person Sealing Well or Bonng