HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ����Q O
Counry Name
WELL AND BORING SEALING RECORD Minneso a�Unique Well No. �
�6I1l1e �.Q Minnesota Statutes,Chapter 1031 or W-series No.
�Leave Dlank ii nol known)
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
oreno ��s a3 z6 3�-tro�: v — d
.
GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depih ft.
LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location � ingle Aquifer ❑Multiaquifer /�
Measured Estimated Date Measured��✓�'�' �/�
WELUBORING ❑
• Q �VJater-Supply Well ❑Monit Well r
Show exact location of well or boring Sketch map ot well or boring � �Env.Bore Hole Other
in section grid with"X" location,showing property - ❑ �ft. �below ❑above land surface
N ' � lines,roads,and bui�,gs. CASING TYPE(S) ;
� Steel ❑Plastic [J Tile ❑Other
� --'--- --'--- ---`-----'-- � ELLHEAD COMPIETION
� •
W : ; ; ; ET
W
.: � � _;____r__ . Outside: ❑Well House ❑At Grade Inside: asement Offset
—;--- --�-- - � ��'
'h Mii� ❑Pitless Adapter/Unit ❑Buried ❑Well Pit
:` --�--- --�-- --�----�-- I '1 ❑Buried
L ❑Well Pit
S ❑Other
�1 Mile� ' ❑OthBr
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameter � Depth � Set in oversize hole? Annular space initially grouted?
oper y owners mai ing address if diflerent than well location address indicated above ��
_�in.from_�� to /I!/1 ft. ❑Yes �lo ❑Yes ❑No ❑Unknown
1820 �j�kevfev Terzace
i�v�Q araa�0�: � 55356 in.from to ft. n Yes ❑No [�Yes ❑No ❑Unknown �
in,from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
i
Well owner's mailing address if diflerent than properiy owners address indicated above SCfeen ffom //v * to • �`� ft. Open Hole ffOm to ft.
OBSTRUCTIONS
�Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
/�� ....�
Type of Obstructions(Describe)���G.G ���J"� ¢ ti,,,/�'�l
GEOLOGICAL MATERIAL COLOFi HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
PUMP
If not ISnown,indicate estimated formation log from nearby well or boring.
..— ' � � l TYPe _.
s
r 1 Removed I�ot Present ❑Other
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�vo Annular Space Exists U 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) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�' r ` �
Grouting Material /t,�f�! ����L�1flom �+ to r �� ft. yards� bags
from to ft. yards bags
from to k. yards bags
OTHER WEILS AND BORINGS
qEMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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.
Don Stodola iiel Drlclifo9 Co. ,- Inc.. 1691
Licensee Business m License or Registration No.
�- ,�i- a�;
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY �"� //� ^/ Q ���`������
- i.�i��J� Name ol Person Sealing Well or oring
HE-07434-10 IC#140-0423 sio�a `