HomeMy WebLinkAboutwell info Minnesota Well and Boring
WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 3 6 5 6 4
�o���Y Name WELL AND BORING SEALING RECORD M���esota���q�e No.
Minnesota Statutes.Chapter 703/ or W-series No.
.�L>�j, ,,,A ��c.,ve biank J not k�owm
Township Name Township No. Fange No. Section No. Frachon(sm. �Ig.) Date Sealed Approxima�e Date Well
� \ or Boring Cons�ruc�ed
+j y ' y, �ia �la '�a f ""' d. -�-. �i _' , �,
Numencal S�ree�Address or Fire Number and Cdy of Well or Boring Location
G T �� '�t � Dep�h Before Sealing � ��� ft Original Depth —��� ft
s
Show exact Ixation of well or boring � ' Sketch map of weli or boring Static Water Level �Accurate
in section grid with-X-. location,showing property lines.
roads,and buildings. ❑Approxima�e
N
� � � i_ 1'
__ ___ _-_ ' �\
{� �� �$ingle Aquifer ❑Multiaquifer ��—fl. —�.- below above land surface
i i i i
_i_ _�_ _i_ _i_ ` CASING TYPE
W i i i i E �. Y'';'.,_ t���'�': �,,,e'
i i i i
i i i i � 1` �y teel ❑Plastic ❑Tile ❑Other
o mile 7
i i i i t
__ _ i_ _i _ _i � '� �.
S t Screen from �o ft. Open Hole from to ft.
�--1 mile--►I , d�'�Y � �� OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME �J*^ �Obstrudion ❑Debris ❑Fill
.r.. ] 1/{� . � :. j w�
�� �� �� Type of debris/obstruction l--J -[ � ���'t` � f' ` �� 1 "
Mailing Address rf different ihan property address indicated above. T� !
Obstruction/Debris/Fill removed? es ❑No
PUMP
�`- rl'�--�:
"' [},�Removed ❑Not Present ❑ Other
i
CASING
RDNE O€
GEOLOGICAL MATERIAL COLOR ,'��qRMA�pN P Mh O
Diameter Depth Set in oversize hole? Annular space initially grouted? -
If not known,indicate estimated formation log from nearby well or boring.
�� . � in.from _�_to �1_� ft. ❑Yes �(No ❑Yes ❑No �Unknown
% `�`
in.from to fl ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from [o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�o Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
m.from to fl. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of peAorator
❑Other
GROUTING MATERIAL
t (j! ,i
Grouting ma�erial !�_ from �_I to _J ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
� i t f
.... �,f� 4{ `� � � � y � from to ft. yards bags
UNSEALED WELLS AND BORINGS
� t/��"� t ��� � f� r��~' � Other unsealed weli or boring on property? ❑Yes �IQo
t
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
Thls well or bonng was sealed m accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
irue to the best of my knowledge.
�''' � /t � {, � 7 � �`�a
Contractor Business Name : License or Registration No.
` ', �
t ;t,.�..� ( jf:�%w'"� `_�° "" '� -
Authorized Representiat�ve S�gnature �i Date
/
'� ; j ; �.,'� . t �
LOCAL COFY '„I ' � �` �-.:%' ., ,, i
Name o/Person Sealing Well or Boring
HE-01434-01