HomeMy WebLinkAboutwell info ELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H j ��9 7 8
� :ounty Name
WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No.
Minnesota Statutes, Cha ter 103I or W-series No.
� (Leave blanh if n0�known)
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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 � y3 ft. Original Depth ft.
LOCATION: Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer [�Multiaquifer ��'S . ' Z
17! ��-���r�� ��aaE+ '�r� (l�Cy�(� ,W}�'E�LUBORING �'Measured U Estimated Date Measured
�y Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of weli ng �
in section grid with"X:' location,showing pr per I_�Env.Bore Hole ❑Other _��ft. �,below [�above land surtace
N lines,roads,and bw ings. CASINGTYPE(S)
�' --'----'-----'— --'-- ��:
�� � �]Steel [.]Plastic �_.]Tile []Other
, � � � �
,� -
' '--- ' ` '-- ��.i� '��.� WELLHEAD COMPLETION `
W � ' � E T l � U A[Grade Inside: �Basement Offset
. ,___ , r__ Outside: ❑Well House �`
I �
�: , , , i Miie _� �;Pitless Adapter/Unit ❑Buried i���Well Pit
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- --- - --- -- 1 ,., ) ❑Buried
S ��Well Pit
, T , ' ;� ❑Other
�1 Mile� j ❑Other
PR I �MP Y A 1 CASING(S)
r _ ���COW�i�Ld��i Diameter Depth Set in oversize hole? Annular space initially grouted?
Propeny owner's mailing address if different than well location add�ess indicated above ,i in.from � to �� S ft. [.]Yes u No U Yes ❑No ❑Unknown
� G17 (?ak St
- FarrRin�;ton, i�u� 5 JVG'+ in.from to ft. [_]Yes �_�No f]Yes ❑No �;Unknown
in.from to ft. �j Yes �_�No n Yes ❑No ' :�Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
?
Well owner's mailing address if different than properry owner's address indicated above SCreen from_�� S to ��7 ft. Open Hole from____ ____to ft.
OBSTRUCTIONS
�]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill I�-]No Obsiruction
Type of Obstructions(Describe) ��t/F �'� j� t
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? �Yes L]No Describe
FORMATION
PUMP
If not k�own,indicate estimated formation log from nearby well or boring.
i /� (�
�Jr �_�._ ` l �/ TYPe —
❑Removed [�Not Present ❑Other
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE NOLE:
�� q]No Annular Space Exists ��Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
���. .____.__in.from _._________to tt. ❑Perforated U Removed [.
in.from to ft. ❑Perfora[ed []Removed
Type of Perforator
❑Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material �f�I� t"f" � � � from y� 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 Ofi REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesoia Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
�on Stc�lola t•Tell ��ilZin�; Ca., Inc. 1h�31
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Licensee Busine�N e License or Registration No.
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died Representative Signahfre Certified Rep.No. Date
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� ����, " 3119�8 �` _�—� �-- � .__�,, _a 1�.
t Name of Person Sealing Well or Boring
- HE-01434-13 IC#140-0423 � sn2R