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Home My WebLink Aboutwell info Minnesota Well and Boring n WELL OR BORWG LOCATION MINNESOTA DEPAFiTMENT OF HEALTH Sealing No. H ��O lJ H _.. WELL AND BORING SEALING RECORD M��nesota u��q�e 2 � g� County Name or W-Series No. �� Minnesota Statutes.Chaptei 703/ ��edVe b�a�k o �� .,,,,��'. Township Name Township No. Range No. Sedion No. Fraction(sm. �Ig.) Date Sealed A r imate Date Well .� or Boring ConstrudeYf .�v�.�� rran�� t 17 7 3 17 a 1;;{?ti�,� �„ ^ -. ,,, �L;:IIl F: ~-� ,: Numerical Street Address or Fire Number and City of Well or Boring Locahon .y� � ` 3329 C�y::'�c�1 A[3y swa,�,i ��(14� �� Depth Before Sealing G t (t Original Depih '�-�-; ft. Show exact bcahon of well or boring Sketch map of well or o�ng Static Water Level �Accurate in section grid with��X��. location.showing propert Gr� roads,and bui � s. ❑Approximate N _i i i i_ —'----�--r / i_ _i_ _i_ _i �Single Aquifer ❑Multiaquifer ��ft. � below above land surface i i i i � \ _i_ _�_ _i_ _i_ ,ti, �'`� CASING TYPE W i i i i E � �� i � � � _i_ _�_ _r_ _�_ � � � � �/ , teel ❑Plastic ❑Tile ❑Other e mile * i i i i 0� -.__._.. _i_ _ _ _1 _ _I � � r l I S Screen irom �� to 4 � fl. Open Hole from to ft. N— 1 mile� �.._� . OBSTRUCTION/DEBRIS/FILL ❑Obsiruclion ❑Debris ❑Fill PROPERTV OWNER'S NAME J�.ue HC1�Z Type of debris/obsiruction ��f Mailing Address rf different than property address indicated above. Obstruclion/Debris/Fill removed? ❑Yes ❑No [�t/R .3� PUMP Nr�.-�rre, I�. ��;�a� � � �1 ❑Removed Q�pt Present ❑ Other � CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? I(not known.indicate estimated forma6on log irom nearby well or boring. � i' � �L in.irom �—�o —� ft. ❑Yes �No ❑Yes ❑No ❑Unknown in.from �o fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to tt ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: i �No Annular Space Exists - ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in,from to fL ❑Perforated ❑Removed in,from to fL ❑PeRorated ❑Removed ; Type of perfora�or ❑Other GROUTING MATERIAL I Groutingmaterial^AJ.��f �.L/�r�,<./from � ro �-� ft. yards �_bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to ft. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes o LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this repoA is true to thGY�q f y n le e. C�rt� {�()'{�� y,1p� �y- 7��,yv 1.JlAY ��'i ♦*.-•.�.� i�.i 1�l�I t`rl� U_'.� tav�.. L 7� �[`. Contractor Business Name License or Registration No. " _.,......, ,• ! "� ��. ,�"/-i'� � �- ...- 6-2f�i `Q'uthorzi ed Representatrve Signature Date LOCAL COPY H 5 5 0 0 8 J�.1ll AlltOIiS�] Name of Person Sealing Well or Boring HE-01434-01 Minnesota Well and Boring ��O O� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H � �o��Y Name WELL AND BORING SEALING RECORD M��esota��q�e No. ��1 Minnesota Statutes.Chapter 103/ or W-series No. iLeave biank if no�knowni Township Name• ��Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approxima[e Date Well viVi3ti 1 1 ( �3 17 4��1��J�14 � "",-,�yr � or Boring ConsVucted t..�`., Numencal Street Address or Fire Number and City ot Well or Boring Location � � :�s29 �tal gay R�,-�d (�c��o, �� Depih Before Sealing �� ft Onginal Depth �` Fl Show exact location of well or bonng Sketch map of well 02 bQnng Stahc Water Level ccurate in section grid with��X��. location.showing prope li�. roads,and b I�gs. ❑Approximate N _� � � _ _�_ �'� / r -�' -r � �,� i`�� ingle Aquiter ❑Multiaquifer `��tt. below above land surface i � i i � \'\ _I_ _J_ _1_ _I_ � CASING TYPE W 1 I I . I E \� I I I I �� ~ -r -�- -r- -r - i � i i „� i""' � Steel ❑Plastic ❑Tile ❑Other _ _ b�e � I I I I I I I I � ,�� S _j � Screen from to � fi. Open Hole hom �o ft. �—1 mile—� �;`J OBSTRUCTION/DEBRIS/FIIL PROPERTY OWNEfl'S NAME . �Obstruction ❑Debris ❑Fill Jirni�e Holtz Type ot debris/obsiruction ��'�� Mailing Address d different than property address mdicated above. Obstrudion/Debris/Fill removed9 ❑Yes ❑No BGX�V PUM P NdVG'iLZ@� �[i. �?r3�� -�� ❑Removed ot Present ❑ Other � CASING GEOlffGICAL MATERIAL COLOfl HAHDNESS OF FROM TO FORMATION Diameter � � Depth Set in oversize hole? Annular space initially grouted? If not known,indicate eslimated formation log from nearby well or boring. '�'/ i �in.from �L to �..� ft. ❑Yes �No ❑Yes ❑No ❑Unknown in.from �o ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CAS�NGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing PeAoration/Removal in.from to fL ❑Pertorated ❑Removed in.from to ft. ❑Perforated ❑Removed Type o(perforator ❑Other GROUTING MATERIAL Grouting material A.,JE;^� f��'�'7'r��✓� from � to �L fl. yards �bags from to tt. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to ft. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑Yes o LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The informa6on contained in ihis report is true to the best o(my knowledge. Gt.?I3 S'I�C�f.�T,l� WF�,L, D�2II.I,ING O0., Il�TC. 271!"i Contractor Business Name License or Registration No. '�� L3""G(T74 __j;,��rf �, — �.�'' i;:; �h ¢ Representative Signature Dafe Jim Ant� ��A��G�� H 55009 Name ol Person Sealing Well or Boring H601434-01