HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 7 4 4 4 4
County Name
WEL�. AND BORING SEALING RECORD Mennleso a�Unique Well No.
Minnesota Statutes,Chapter f03J or W-series No.
Aenn «ea�e b�a�k���o,k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
'' 2�' O�-T
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GPS Latitude degrees___ minutes____ seconds Depth Before Sealing �CO�l ft. Original Depth_ tt.
LOCATION: Longitude degrees___ minutes seconds
�- - A FER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer []Multiaquifer �/ M �.�y
/^��� E BORING 'l�uleasured ❑Estimated Date Measured ��//'� (.)/'7 __
1�5 `^r++�-v��8 �J� Qr(�'(� � 3 Z �Va�ter-Supply Well ❑Monit.Well �
Show exact location of well or boring Sketch map of well or oring �/
in section grid with"X:' location,showing pro rty �Env.Bore Hole ❑Other �t ft. '�below ❑above land surface
� lines,roads,and buil /
N 95� CASING TYPE(S)
--'--- --'-----`- --'- yt ��
� ;�teel ❑Plastic ;]Tile ❑Other
"�"'-'�"'---`-- ---`-- WELLHEAD COMPLETION
W : : ; � ET
� � � � _ Outside: i_;Well House ❑At Grade Inside: [�sement Offset �
'h M'ie ❑Pitless Adapter/Unit ❑Buried ❑Well Pit
--:--- --r-----�-- ---:-- 1
❑Buried
' S ' ❑Well Pit
❑Other
��Mile� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �
� Diamet f� ' Depth� Set in oversize hole? Annular space initially grouted?
Pioperty owner's mailin a ress if different than well location address indicated above �in.frOm � to�fl. ❑Yes 1l0 �.�]Yes [�No ��1 UnknoWn
in.from ta fl. ❑Yes ❑No ❑Yes �No ❑Unknown
_in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t
// /y/y� ►
Well owner's mailing address iF diflerent ihan property owner's address indicated above Scfeen from to ft. Open Hole from_! L�!'� to /`��./ fl. �
OBSTRUCTIONS
,�ods/Drop Pipe '�!Check Valve(s) ❑Debris ��]Fill , ���,No ObsVuction
Type of Obstructions(Describe)_ ..l 1V/V�J` �;,�� /� ����/`r
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? I�s f]No Describe
FORMATION
PUMP
If not kn wn,indicate estimated formation log from nearby well or boring. T e ��� �u m
r..l�i �� YP
�" emoved [�]Not� ❑Other
)' _ �•+�:�� --� �.,,,_j .J..J1if3_�L. M�OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING#ND BORE HOLE:
- ,/�I I i � [ o Annular Space Exists �,_,I Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Fiemoval
Ep (p
in.from io ft:. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator �
,
..:.. . .; .;. , ....,..�_.._ Oth � ,
.. - . . .. , . ��. B ,_ . ._ :.. ... .. ..._ .,.... .
, ,.
:. GROUTING MATERIAL(S)' � � (One bag of cement-=94 Ib�.,one bag of bentgnite=50 Ibs.) �r,
=- . , ,. . .Grouting.Material /v��� `�'""-1r�rii � to�"�_�__ yards /� ba s g
9
' from to ft. yards_.__ _ ._ bags
. � _ ____ _ from to .__ ft. yards bags
� . . .. . ... . . . . . .. .. .. . ' ` ..: .. . ... . .. .OTHER��WELLS AND.BORINGS `:
REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I �'� How many?
". � � � � �� � �� "�""'�� LICEN3ED OR REGISTERED�G.ONTRACTOR CERTIFICATION.. �"
This well or boring was sealed in accordance with Minnesota Rulgs,Chapter 4725.The information contained in this report
is true to the best of my knowledge. � � . " '�
: l�an Seodola «e1I Drillin�Co., Inc. 1b91 :°
�� � � �� �� '�- � � � � ��-�^ �� ���-�-��� � .. Licensee Bus;n�ss Name � � �+"'� License or Registration No.
� . :_.:. . . .
�. ' . . . � .., .;
. . :. �J �1 ��
..: � . � „_�
:
Ce e e resentahve Sigii re � GeKi/ied Rep.No. , Date
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-- -------- � .
_ , u 274444 w � Y��,,,-�.- �
,�P.L.COPY n Name ol Person Sealing Well or Bori
____ _ ---- -
�_ HE-01434-11 IC#�140-0423'-.... .... . ... .. . .. .. . .. _ ... ..,:, . 2/oea