HomeMy WebLinkAboutwell info wELL OR BORING L�CATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 1816 9
Counry Name
WELL AND BORING SEALING RECORD MinrliesoNa Unique Well No.
�tH1�P�.t1 Minnesota Statutes,Chapter f031 or W-series No.
(Loave blank ii no�known�
Township Name Township No. Range No. Section No. Fraction(sm-s Ig) Date Sealed Date Well or Boring Constructed
��° i 28 3 3 41 I2 ,� ,� �,
2
GPS Latitude degrees minutes seconds � Q/ /
LOCATION: Depth Before Sealing ft. Original Depth—__��.___ ft.
�ongitude degrees minutes seconds p FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �(
WELUBORING I/'�Measured ❑Estima[ed
7
�Water Supply Well ❑Monit.Well �� /
Show exact location o well or boring Sketch map of well or boring �
in section grid with"X" -, location showing pro�erty Env.Bore Hole ❑Other ft �below ❑above land surface
lines,ro�ds,an�l buildin�.
N �<� �� "� CASING TYPE(S)
..�!
-�- -�— --�-- --�-- �
Steel ❑Plastic ❑Tile ❑Other
W —�- -- - — -- — E �y,''• WELLHEAD COMPLETION
� , , , � t + Outside: ❑Well House Inside:�asement Oftset �,
---- -�-- -;— --�-- �
�^��� � ❑ Pitless AdaptedUnit ❑Well Pit
---- -i— -�— --i-- I
� ❑Well Pit ❑Buried
S
�—r'"n°---�' ` ❑Buried
PROyP�,E,RTY OWNERT'S NAME/COMAPANY NAME CASING(S)
i'N��t� �7�� 752-473-3773 Diameter Depth f Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above �1
� in.f�Om� t0�.,ft. ❑Yes �o ❑Yes ❑No ❑Unknown
in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE 's
� �
Well owner's mailing address if diNereni than property owner's address indicated above Screen from t0 ft. Open Hole from t0 ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)���fl' �1���T
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 2S ❑ NO Describe-
FORMATION
If not known,indicate estimated formation log from nearby well or boring P�MP ..
�,� • � � ' TyPe �� f �U�
'`^^�'� `�� `�� �Removed ❑ Not Present ❑Other `
i. METHOD USED TO SEAL ANNULAR SPACE BE�:TWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�o Anrular Space Exists ❑ 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.)
w � /y� /j /
Grouting Material%v��� ��/"`��L to�ft. yards bags
_from to ft. yards bags
� . - _from to tt. 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-GERTIFICATION� " � �
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 Stotio�a Well Dcilling Co , Inc 27I72
Contractor Business Name License or Registration No-
- - � ._� �/ .:i y`
esen ive Signature Date
LOCAL COPY H ��H i�� � J"--' �"�^"�s�Y�
Name ol Person Sealin g Wel!"o'Borin g� t