HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �����Q �
WELL OR BORING LOCATION �yELL AND BORING SEALING RECORD Sealing No. �H p
Counry Name � --
Minnesota Unique Well No. � — -- �
Minnesota Statutes.Chapter 1031 or W-series No.
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Township Name Township No Range No Section No. Fraction�sm �Iq� Date Sealed Date Well or Boring Constructetl
4rano il$ 23 �_ �1-�40� <
Numencal Streel Address or Rre Number and Gry of Well or Baing Location +y� � �j f
��� ra�,.�� , pL�a� ��,� ��,Q�O� y�g Depth Before Seal�ng I ISO fl Original Depih / f`� h
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Show exact Ixation of N•ell or boring L't,9 A t Sketch map of well or bonnq �1qUIFER(S) STATIC WATER LEVEL
in section grid with"X". >>J��' location, showing property ��Single Ayuifer ❑ Mulhaquifer
lines,roads,and buildings.
ry WELVBORING Measured ❑ Estimated
. � � � � , �Water Supply Well ❑Monit.Well _ /
�- -�-- --;-- --� �� '
r'.. " � ❑ Env.Boie Hole ❑Other _ _=�,,;�ry. �below
❑above land suriace
W -- - -i-- -i— —i-- E L�� `� CASING TYPE(S)
r
' I I I ,_. �{
� -;-- --;-- --;-- --�- � �` �Steel ❑ Plastic ❑Tlle � Othe�
}1 mile
—�- ---- -,— --�— � CASING(S)
Diameter Depth � Set in oversize hole? Annular space initially grouted?
s e r/
�--r mea�4 M r � in �rom� to ��� ft. ❑ Ves �No ❑ �es 0 No ❑ Unknown
PROPERTV OWNER'S NAME in.from to _ R. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
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Property owner's mailing a dress if aiHerent than well location address indicated above. in.from to . R. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown
SCREEWOPEN HOLE
, ". Screen from�to� ft. Open Hole from ro ft.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction
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Well owner's meiling etlOress if CiHerent Man property owner's address Indicated above. Type of ObStruclions(DesCribe) �1Ur� ��/`� 4" iJ S 1
Obstructions removed? �Yes ❑ No Describe
PUMP �g
ryPe ��7� N�1/�"X�
� (iEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO W Removed ❑ Not Piesent ❑ Other
FORMATION
. If not k{awn,indicate es�imated formatbn log from nearDy well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
• [�lo Annular Space Exists �
•� f ❑Annular space grouted with tremie pipe
❑Casing PerforatioNRerrwval
in.irom to ft. ❑ Pertorated ❑ Removed
in.trom to fl. ❑ PeAorated ❑ Rertwved
a
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material �������+�r�+�m � to�th� yards � bags
from to ft. yards bags
irom to ft. yerds bags
from to_ ft. yards bags
REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes �No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in Mis report is
true to the best ol my knowledge.
Dt:Ft ,'�L!?d+o18 �ell. AL'i 11#.12g GO., I�C s 27172
Conhacror Business Name - ..r°` License a Regisfrefion ivo.
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s. - � .�--�` �-
uthonzed Representative Signehiie Dete
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, .L��:,�,. ,:{��y u �w��A A Name ol Person Sealin�'..�l or Bonng
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