HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 316 9 2 2
County Name
WELL AND BORING SEALING RECORD Menneso a�Unique Well No.
Minnesota Statutes,Cha ter 1037 or W-series No.
�Ay�eA�'��f P (Leave dank it not known)
G3112 ��
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
i�rono 117 23 2� t�TF' N� S�� ?C.> C:;�.; �'�
GPS Latitude . degrees___ minutes__.., seconds Depth Before Sealing� � __ft. Original Depth ft. �
LOCATION: Longitude degrees minutes seconds
�IFER(S) STATIC WATER LEVEL -
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �^ rt
2975 C.asco �01nt RU, ��QL� �UBORING �Measured ❑Estimated Date Measured _J J��'/�� ��
`� Water-Supply Well ',�J Monit.Well r� �,
� Show exact location of well or boring Sketch map of well or boring �Env.Bore Hole ' ',Other_ _
: in section grid with"X:' location,showing property — _— ._— 4'� —h �,below [_]above land surface -
N lines,ro�s,and 4uilding�. CASWGTYPE(S)
,�� IC
--'— - - �- •- � '
"� , ( �Steel [ I Plastic [_�Tile �._!Other _ ���
� � --- ._----�--
'� '"'"" "'"' '`' '- WELLHEAD COMPLETION
1
•� W , . , , E � .
: __;___ __I__ __�____r T y�`° Outside: r,Well House �]At Grade Inside: �Basement Offset
'h Mile A :T
�� --;-----T-----f-----:-- itless A p r/Unit �-� uned � ell P�it
1 [�P� da te � B ��W �:
❑Well Pit ❑Burie ��
S ❑Other
�--i Mile� ❑Other ^
+
z
PROPERTY OWNER'S NATM�E+/COMPANY NAME CASING(S)
�tonec,aoo�i IiLw� Diamete� � Dept�'l � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if ditterent than well location address indicated above _ � _in.from � to ��/ ft. �J Yes �i No �_.�Yes [�.No ❑Unknown
7�f�7 �+�8,Z$ta gl�T� in from to ft. [j Yes Li No �Yes ❑No ❑Unknown
St Lc�uis pack, t��1 55426 - - .
in.from___ to ft. L:I Yes ❑No ❑Yes ❑No ��.1 Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
a . i
Well owner's mailing address if different ihan properry owners address indicated above SCreen frOm / � to��__ft. Open Hole from to ft.
f�OB TRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �]No Obstruction
Type of Obstructions(Describe) ��/UrK �1!�� 4 �/IG J'
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring. '('� 1�.
Type__J= t �U n1�
� �d�-�— �� ��� �Removed �I Not Present I_�Other
j METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
��o Annular Space Exists '�,'��Annular Space Grouted with Tremie Pipe i�Casing Perforation/Removal
___ in.from_ to _ft. [_i Perforated ❑Removed
in.from __to ft. �__�Pertorated ��Removed
i
Type of Perforator _______
r�Other_
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
r
,n / n
GroutingMaterial/�/G,/'�%t,��`��t����rom CO to��" � ft.______ yards__� bags
from to ft. _ yards bags
_ _ from ro __ ft. _ yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes �No 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.
1.km Star�ola We11 Driliin�; Co,. Ir�c. 1691
Licensee Business lyame License or Registration No.
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'Certilied Aepresentative Signature Certified Rep.No. Date
316 9 2 2 � '�'�"��``"
IOCAL COPY H .��•"`" _
Name of Person Sealing Well or Boring
HE-01434-13 IC#140-0423 � sii2R
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