HomeMy WebLinkAboutwell info wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 2 8 6 5
County Name
WELL AND BORING SEALING RECORD Mennleso aOUnique No.
� r1 Minnesota Statutes,Chapter 1031 or W-series No.
"*( �;yr. (Leave blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
f�y '/a '/a '/a J . �- , /�-. . . .
Numerical Street Address or Fire Number and City of Well or Boring Location
��:^.-. �? � � ' „ j j ' ; Depth Before Sealing J� ft. Original Depth �,f ft.
Show exact location ot well or boring � Sketch map of well or boring ppUIFER(S) STATIC WATER LEVEL . , _�
in section grid with"X". location, showing property �Single Aquifer ❑ Multiaquiter
lines,roads,and buildings.
N WELL/BORING �(.Measured ❑ Estimated
� _ ., � �. +� -.._ [�Water Supply Well ❑Monit.Well
_T_ _ � " f �� f.
"`�'�-----•------^-• ❑ Env.Bore Hole ❑Other �ft.
,�below ❑ above land surface
i�
W -r- -i-- -i-- --i- E �,.i` � CASINGTYPE(S)
� i � y
� �
� i i � J�
� � f'- [�cSteel ❑ Plastic ❑Tile ❑Other
-�— -�-- --�-- --�— ,�
� � � � /mile . I.,___r
—�- -�-- —�-- --1-- � ! ( CASING
���������� Diameter Depth Set in oversize hole? Annualar space initially grouted?
q�i mile—�e �_� in.from�_ to�L_ ft. ❑Yes [�No ❑Yes ❑No �Unknown
I i
PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown
. . —
Property owner's mailin address if different than,well location�address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
r `-. . Screen from to ft. Open Hole from to ft.
O B ST R U C T I O N/D E B R I S/F I L L
WELL OWNER'S NAME [�r Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
i
�,.,y =' �..,_.L.. J
Well owner's mailing address if diNerent than properry owner's address indicated above. Type of Obstruction/Debris/Fill � �!`� � �, � �' 'f
Obstruction/Debris/Fill removed? Yes ❑ No
PUMP
Type �. ,. �
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed �� Not Present ❑ Other
FORMATION
If not known,indicate estimated(ormation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exits
�V a
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
Grouting Material j from � to� tt. yards �`�F bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes ' No
, � LICESJSED OR REGISTERED CONTRACTOR CERTIFICATION
4 ��, , , ,
, �' 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.
i �
Contracror BusinE§s Name' License or Registration No.
r
Authonzed Representative Signature ` Date
Name ol Person Sealing- e!I or Bonng -
LOCAL COPY H �; � � � �j �
HE-01434-02
10/95R