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Home My WebLink AboutWell info � . WELL OR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 110 716 WELL AND BORING SEALING RECORD Sealing No. Counry�ame Minnesota Unique No. � - Minnesota Statutes,Chapter 1031 or W-series No. � ��- !� (Leave blank if not known) To ship Name To ip No. Range No. Section No. F�ction.(sm.-s Ig.) Date Sealed Date Well or Boring Constructed j4; � l:� � - .�!..i �--'i�'i `-�� ; �rTumeYcal t eet Addres's or Fi e umber and City ot Well or Borin Location j l ,7 � ` ;,� � Depth Before Sealing / � ft. Original Depth tt. I Show exa�ct-'locati� of well or boring � ch map of well or boring AQUIFER(S) STATIC WATER LEVEL in section grid with"X". location, showing property g Single Aquifer ❑ Multiaquifer lines,roads,and buildings. N WELUBORING �Measured ❑ Estimated � �Water Supply Well ❑Monit.Well �„� - - - - -- -- --i-- �{ ❑ Env.Bore Hole ❑Other r � tt. ❑below ❑above land surface W --�- -�-- -�-- --i-- E CASING TYPE(S) � � � � � � � i --�- -�-- --�-- --�-- [�Steel ❑ Plastic ❑Tile ❑Other '/.mile ' ' ' '_ CASING --- -'-- --�- --1- � ' ' ' ' � Diameter Depth Set in oversize hole? Annualar space initially grouted? S G' � Yes No Unknown �—t mi�e—� _� in.from � to fl. ❑ Yes ❑No ❑ ❑ ❑ PROP,€R'GY OWNER'SNAME in.from to ft. ❑ Yes ❑No ❑Yes ❑ No ❑ Unknown '�. ��r. ��:..::� : � ;'� . Yes No Unknown F Property owner's"mai ing address if di, nt than well Ibcation address indicated above. in.from to ft. ❑ Yes ❑No ❑ ❑ ❑ SCREEN/OPEN HOLE Screen from � to�_ ft. Open Hole from to ft. O B STR U CT I O N/D E B R I S/F I L L WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mailing address if diHerent than property owner's address indicated above. Type of Obstruction/Debris/Fill 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) y.� 7 Grouting Material " 1��J*- � ��ry�4•from f to �' ft. yards bags �- . - from to ft. yards bags from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES INSEALING UNSEALED WELLS AND BORINGS %j �-`� � ? - Other unsealed well or boring on property? ❑ Yes � No � �''f'✓� -Y � � � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �f- r �.,�;8=-_ . 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. �� '� ; j �'`�,� x f %�7�f,�/s.r;�,� ' : , Cont2ctocBG s anle � ��- �.� l L�cense orRegrstfahon No. � l %�r' � /N2..�.... 'f !/�r f 6 � � f / ! Auth�p�e�n�(b�Signa nI�' ,- �� !' � D�te � _� � k ♦ J " F / 1 /1 7.� _�I^;��f7, ..^�.f! ! � Narp�o%4�ersOtf,Sa�lintf t�kll or8bring "-` LOCAL COPY H � � � ! � � HE-01434-02 10/95R WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � �"�� County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. � Minnesota Statutes,Cha ter 103i or W-series No. '�E'fd21P°')J Tl P �ea�e e�a�k,,�o�k�ow�� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sea�ed Date Well or Boring Constructed Or�no 117 ?3 2�1 S�? "'�' �K+� �1 T 1 j GPS LOCATION— decimal degrees(to four decimal places) 1 n ! Depth Before Sealing__ 1�,> ` .__.__ft. Original Depth_________ft. Latitude . Longitude __ ,�yg�IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ��tiingle Aquifer �'��Multiaquifer .� ..�R,�� V [� WELUBORING [�leasured ��,__i Estimated Date Measured_��" �. ��! � �nl� ('�sco ?'r�3�t �'�, �r��o 553�1 " �Water-Supply Well jJ Monit.Well �/� � Show exact location of well or boring Sketch map of well or boring -- in section grid wiih"X° location,showing property Env.Bore Hole ❑Other ft. �below [;above land surface N lines,roads,and buildings. CASINGTYPE(S) � --'-- --y----`-- --'— � ��„ Steel ��Plastic �Tile ❑Other ' '-'- ' `' `-- � WELLHEAD COMPLETION W � � � E �� _�. �. � ,__ T �, e� Outside: �Well House i_]At Grade Inside. ��Basement Offset � 'h n�tiie � � �pitless Adapter/Unit ❑Buried ��Well Pit a --,-- --,-- --.-- --: 1 d ❑Well Pit '�_�Burie S e ❑Other F-1 Mile-�� " L �� ❑Othef ______ x r _». �� PROPERT�OWNER'S NAME/COMPANY NAME CASING(S) F�ra Stannt�c� Dia ter� � Depth � Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different than well location address indicated above �� in.from� to �� ft. ❑Yes �lo ❑Yes ❑No �Unknown in.trom_ to ft. �Yes "I No ❑Yes ❑No ❑Unknown _ in.hom_ to R ��Yes �No ❑Yes ❑No (�Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE t ' �� Well owner's mailing address if different than property owner's address indicated above Screen from �� to �� ft. Open Hole from to tL � OBSTRUCTIONS ,�Rods/Drop Pipe ❑Check Valve(s) ❑Debris `_,�Fill ❑No Obstruction � /_�,�y� � ...r Type of Obsiructions(Describe) t��'✓f:f< /��- 4 �� _. __ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? I'�es ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. . TyPe �/� -�,�- �5 � � - �emoved `'�Not resent []Other ,_ ___ METHOD USEDTO SEAL ANNUTAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: �.(Jo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Perforation/Removal in.from to __ ft. ❑Perforated ❑Removed - ____,_in.from to_ ft ❑Perforated I]Removed :�� Type of Perforator__ VARIANCE Was a variance granted from the MDH for this well? i,^Yes o TN# �• GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) y� / / � GroutingMaterial N<AT��(//f� m � to f �} ft._ yards � bags s� from to ft. _ yards bags �;: ---- ---.._ :� from to ft. yards _ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? �,_J Yes � No How many?____ LICENSED Ofi 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 ihe best of my knowledge. non cta�t�la tdell Dcilliri�; Co,. Inc. 26�31 Licensee Business(Y2me � . License or Registration No. ' �.� �� = �� ,,� 11-5—I4 , .,� ��rtifi�eed Representative Signature Certified Rep.No. Date . LOCAL COPY H � �4� 3� 9 9 Jim Antonson - ------------ Name of Person Sealin Well or Borin - HE-01434-14 IC#140-0423 sn3a 3