HomeMy WebLinkAboutwell info wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring� ��`,�:., 10 4 9 2 6
County Name WELL AND BORING SEALiNG RECORD Minnesota Uni9y �. �,
Minnesota Statutes,Chapter f031 or W-series No�,�
� � (Leave blank if not�d�n'
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
4ra�so 118 23 3b �Y�38 � �`
Numerical Street Address or Fire Number and City of Well or Boring Location /� � �/ j
122 �11�15T t�1i+L2� �� �as� 55391 Depth Before Sealing ��[J ft. Original Depth�7� ft.
Show exact location of well or boring Sketch map of well or boring AqUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property u�gle Aquifer ❑ Multiaquifer
lines,roads,and buildings.
N WELUBORING ❑ Measured ❑ Estimated
� � � � �fY� � ater Supply Well ❑Monit.Well �
� +
i � � �
T -�-- --�-- --�-- � �.
___.,__ ❑ Env.Bore Hole ❑Other ��'�R. �below ❑ above land surface
yy --�- -;-- --;-- --�-- E CASING TYPE(S)
� �
� � � �....
� �'t
� � � � } �,r.'� teel ❑ Plastic �Tile ❑ Other
' j � _,.._._...._.�.�. .:..
'k mile t .
' ' ' ' CASING
-�-- -�-- ---i-- --�-- � #
; Diameter Depth Set in oversize hole7 Annualar space initially grouted?
L� /
p(�-1 mile� - . : � �/in.from�_ ro��p ft. ❑ Yes 14'No ❑Yes ❑No ❑ Unknown
� _ ... J�� ... E� . . . �..,i`� 1�
PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
m i e�s i different than well location ad ress in icate above. in.from to it. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
SCREEWOPEN HOLE
s ,) j
Screen from�_to /�� ft. Open Hole from to ft.
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME �[]/Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
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Well owner's mailing address if different than property owner's address indicated above. Type of ObstructioNDebris/Fill ��AIL/f'Ij �I�' � ,��1
Obstruction/Debris/Fill removed? es ❑ No
PUMP
Type��,,,,� /✓1 l��
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log rrom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
j �!]/f�o Annular Space Exits
�\
� � ❑ Annular space grouted with tremie pipe
!f�l ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to n, ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
/
GroutingMaterial , n � to��ft. yards _�_ bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOUHCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes No
LICENSED OR REGISTERED CONTRACTOR CERT ICA ION
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.
—�M Sto�ltt1�17 ]�"i 1 jinb C.n_� _Tnc_ 27172
Contractor Business Name License or Regishation No.
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i
r' . "'presen 7ive SignaWre'" � ``"" �Date
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LOCALCOPY H
`� 0 4 9 2 6 Name of Persb'n`Sealing Well or Bonng
HE-01434-02 10/95R