HomeMy WebLinkAboutWell info wE��OR BORING LOCAnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' ������
Courlty Name
WELL AND BORING SEALING RECORD M nnlesoNa Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
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Township Name n 7 ownship No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
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GPS Latitude degrees minutes seconds y ��
LOCATION: Depth Before Sealing � ft. Original Depth ft.
Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and C'dy ot Well or Borinq Location � Single Aquifer ❑Multiaquifer
� � WELUBORING �Measured ❑Estimated
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Water Supply Well ❑Monit.Well
Show exact location of weli or bonn-� Sketch map of well or bonng "
in section gnd with"X" (f location,showing property ❑Ern.Bore Hole ❑Other -x - ft. �]below ❑above land suAace
lines,roads,and buildings.
N Y�{ CASINGTYPE(S)
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�� -T- -�-- -,-- -r- ..-�-----"\ ;:. ... �' ..
� ' ' �? �]Steel ❑Plastic ❑Tile ❑Other
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W —�- -;-- - -- -- -- E i=` f WELLHEADCOMPLETION
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,. , � � � � --� Outside: ❑Well House Inside: �Basement Offset
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l�mb �� � ❑Pitless AdaptedUnit ❑Well Pit
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Z ❑Well Pit ❑Buried
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�—"'"�°—�" ❑Buried
PROPERTYOWNER'SNAME/C P NAME CASING(S)
� �€ r.'-� � �j�. Diameter Depth Set in oversize hole? Annular space initially grouted?
Property owrier's mailing � ss it different than well location address indicated above 4�"�` `�
. � � in.ffom_;,_ to i;l�..-j ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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� j f )- �r� in.f�Om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
�+j � . ��� r '�-r:� .sP'�€.,,,.`-r'"if
i 1 ;_.i.�t in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
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Well owner's mailing address if ditterent than property owner's address indicated above Screen from,''� `� ,'?to�ft. Open Hole from t0 ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
� Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe
FORMATION
If not known,indicate estimated tortnation log from nearby well or boring PUMP
Type
❑ Removed � Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
❑ No Annular Space Ezists ❑ 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) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material , � f from�to �� R. yards - � bags
from 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 � 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 kfowledge.
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Contractor Business Name License oi Registration No.
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Autlfanzed Representative Signature / f � . Date
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LOCAL COPV H L� i ��� , ��� , �; �f � ,L ��� l.{
Name ol Person Sealing Well or Boring