HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��Q�Q�
WELL AND BORING SEALING RECORD Minnleso a�Unique WeII No. V �'
Counry Name -
Minnesota Statutes,Cha ter 1031 or W-series No.
HOIIIIAj��A p ,�ea�e o�a�k���o�k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
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�� GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depih ft.
LOCATION: Longitude degrees minutes__ seconds p UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City ot Well or Boring Location . Single Aquifer ❑Multiaquifer � �y�L /�
1 08 /r1.eVv �hi.! �� OrO,�OI- �• WEWBORING �Measured [�Estimated Date Measured,.'r�fJ = �✓/��
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Water-Supply Well ❑Monit.Well 1
- Show exact location of well or boring Sketch map of well or boring /�,a
in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other v`� ft. �below ❑above land surface
N ,� lines,roads,and buildings. CASING TYPE(S)
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� --'--- --'--- --`-- --'— �.
� � � � �
Steel ❑Plastic ❑Tile ❑Other
�' --'----i--- ---`-- --`-- � WELLHEAD COMPLET�ON
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� W ; ; ; : ET
:: � � � � � • ,_a� Outside: ❑Well House �]At Grade Inside: j�Basement Offset ��
— ----- --- ----- -- �7
�� � � � � e '� itless A p dUnrt ❑ uned . ell Pd
h
�P� da te ' B �W
. --.----r-- --�----.- 1 ::
❑Buried
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�]Well Pit []Other
�-1 Mile-� :"'1(��r.,.a, ....11_.F3.-.ca...� i�� ��OthOf
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PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
t�ark D Wf ili��� Dia eJef /`�1 Depth � Set in oversize hole? Annular space initially grouted?
.Properry owner's mailing address if diflerent than well location address indicated above �in.from_ ( to �� ft. ❑Yes �No ❑Yes [,No ❑Unknown
I QZ � JWb S�r=e�t St� 1 in.from to ft. ❑Yes ❑No �]Yes ❑No ❑Unknown
Chaaka,. I�i.. 55316
61 i�251�97g0 _in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t �
Well owner's mailing address if diflerent than property owner's address indicated above Screen ffom �� to /O� ft. Open Hole from to ft.
OBSTRUCTIONS
[�ods/Drop Pipe [_j Check Valve(s) ❑Debris []Fill ❑No Obstruction
Type of Obstructions(Describe)�N��� / .L�� ; /�u��/`
' GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? s ❑No Describe
FORMATION
PUMP
If not known,indicate estimated forma[ion log from nearby well or boring. �Ut2 �m�
� TYPe �
�� � �
�Removed �]Not Present ❑Other
JMETHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists �Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to_ ft. I�Perforated �]Removed
in.(rom to _ft. �]Perforated []Removed
Type of Perforator
[j Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bent�nite=50 Ibs.)
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Grouting Material/`�'��� ��`�r^�Tr6m Q to ��ft. yards � bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS �
s
REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes � o 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. �"
DON STODOI.� tlELI. D8ILL2NGC0.. I�iC.. 1691
Licensee Business Name � License or Reg�stration No.
; �� � ' Sss .� �o. O�, �
Ce i r �tative 3/gnature ,i'� Certilied Rep.N¢ � Date
_rC^.�COrY H i.�V�V� \/`��.-� `._��/�;�trr'✓a,�ly1
Name ol Person Sealing Well or Boring
HE-01434-10 IC#140-0423 � . .. Sio�R ��
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