HomeMy WebLinkAboutWell info WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I '9 ���� O
County Name
WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. �
Minnesota Statutes,Cha ter 1031 or W-series No.
q P (Leave blank lnolknownl
�'�enn+� in
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed �, Date Well or Boring Constructed ��� i�
(?COriO 1 7 $ _%_. { �'� �...� � ,�,
p GPS LOCATION- decimal degrees(to four decimal places) �9^ �" ,� `F � � 1 J
; Depth Before Sealing__ � �/ � ft. Original Depth_.. .__ r`.h.'��'
Latitude_ Longitude
AQUIFER(S) STATIC WATER LEVEL
� Sin le A uifer Mul�ia uifer ��'��"`" "
Numerical Street Address or Fire Number and City of Well or Boring Location �. 9 9 ❑ q . _ � F
¢ 'G) WELUBORING [�Measured �,.j Estimated D�f�ur�f_i � � ��w+
392� Cherr� Ave �r�l�{3 J�JiJ`t �Water-Suppiy Well i;Monit Well
Show exact location of well or boring Sketch map of well or boring -��Env.Bore Hole .��Other � ;P ft. ��below ']above land surface
in section grid wi�h"X" location,showing properry �-
N lines.roads,and buildings. CASWGTYPE(S)
--'--- --i-- ---'-- ---'-- �
�Steel []Plastic (�Tile [�,Other
--'--- -'--- --5---+-- WELLHEAD COMPLETION ''�
. W ; ; ; ; ET _
. � � � � Outside: ��`:Well House ❑At Grade Inside: � I Basement Offset `�
Y�nn'�ie �Pitless AdaptedUnit �I Buried ;�Weli Pit
-- - - I �Buried
1 ]Well Pit
S ❑Other
�-i Mile� ❑Other._,._ --
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� e 1 , Diameter /' Depth Set in oversize hole? Annular space initially grouted?
Properry owner's mailing address if different than well location address indicated above �in.from V t0��t. ❑Yes `�Vo ❑Yes [i NO ❑Unknown
253 Iake St E
in.from to ft. �Yes '`j No r j Yes ❑No ❑Unknown
tdayzata, '�r1 55391
in.trom to ft. `Yes ��No ❑Yes [�No []Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
Screen from ���� to / �� ft. Open Hole from ro fl.
Well owner s mailinq address if diHerent than property owner's address indicated above �--- — ----
OBSTRUCTIONS
'�Rods/Drop Pipe ;...J Check Valve(s) �_�Debris u Fill ;�:No Obstruction
- Type of Obstructions(Descnbe) ,t.�{� ��--�""___ _____. _
GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? Yes I,_.�No Describe
FORMATION
PUMP '
If not known,indicate estimated formation log from nearby well or boring.
�.--
f-
Type._.__. r,,...a �cve-- _
�;Removed '�Not Present I�Other____
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
[�No Annular Space Exists j_;Annular Space Grouted with Tremie Pipe �_J Casing Perioration/Removal
in.from_ to______ __tt. ]Perforated ]Removed .
___in.from __ _ to____ ft. 'i.]Perforated ]Removed
,� Type of Perforator `'
VARIANCE
Was a variance granted from the MDH for Ihis well? ';�Yes �No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag ot bentonite=50 Ibs.)
Grouting Material � ` -7 r�-°.��-� from ���.�__ to.__{��! �ft. _ yards__L (�. bags
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? ❑Yes i 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 ot my knowledge. �
�
Don Stcxlola i�ell Drillin� Ca�_ Inc._ 1691 �
—---. --- - ---- - --_ –
Licensee Busi�Name - y License or Registration No. r
. � Y
- . -, . ���..� � �41J'i> �
. ,�;t � - ..---. .__. __..
e i/1 f7epresentative Signatuie `� � Certilied Rep.No. Date
H 3 2 9 410 Ti� �e��r —
LOCAL COPY Name of Person Sealing Well or Boring
HE-01434-14 IC#140-0423 5n3A �