HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ������ �
WE��op Bop�N��o�AT�oN — WELL AND BORING SEALING RECORD sea''"9"°. �H
County Name Minnesota Unique Well No. I ---
Mmneso�a Statutes.Chapter 1031 or W-series No. � _ �
r�el9�l��J�i3 �.�.w�n�ak��
Township Name Township No. Fiange No Secaon No. Fracuon�sm.-i Ig� Oate Sealed Date Well or Bonrg ConsTructea
f_}[Oflb 1�� �� �� c�ir�"Q'T3�'. - �� -,� =
Numencal Street Address or Flre Numbe�and Gty of Well or Boring Location _ ,
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7�z� ��J£')�QD(��i �j�j�� �/�Q['!Q �5�'9 2 Depth Bebre Sealing � n Origmal Depth _�"7(' tt
Show exact locahon ol v,�ell or boring Sketch map of well or�oring. AOUIFER(S) STATIC WATER LEVEL
in section grid wdh"X" bcation, showmg pr perty Sing�e Aywfer f] Mulhaquder
Gnes,roads,and bwldings
N , v � WELUBORING Measured ❑ Estimatetl
� � ; � . � [�Water Supply Well ❑Monrt.Well
j � � ; � Q1Env Bore Hole ❑Olher _._ �_ft �below ❑ above land surtace
� � � � . �
W --�- -=-- -=-- --=-- E ' � � � CASING TYPE(S)
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� � � i •
� { , �
� � � - f .
' ' � .J �Steel � PlasUc �Tile � Other
_�_ _�__ _�__ __�__ .
ylmile -._____."-_ . . —
-�-- -=-- -�-- --�— I i CASING(S)
� �� ~ Diameter Depih J Set in overs¢e hole� Mnular space initially grouted7
LL�� S __ - ,- ,, /l � l�'
y�r mrre� - in.from� �o ft. ❑ Yes No ❑ �es ❑No ❑ Unknown
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PROPERTV OWNER'S NAME in.from ro tt. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
�'+ . !- ..
Property owner' aifing ad ress i Ai erent than wel locanon address indicated above in.from to ft. ❑ Ves ❑ No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
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Screen irom to R. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME [��Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
T
Well owner's maili address if diflerent than r e owner's address indicated above. `° �� �r?�'�� '-1 f�' '�"t��`
ng p op rty Type of Obstructions(Describe) ,
Obstructions removed? �Yes ❑ No Describe
PUMP
Type l�`---�.. � !:i"�t'
GEOIOGICAL MATERIAL COLOR HARDNESS OF FROM TO qt.Removed ❑ Not Present ❑ Other
FORMATION
� If not known,irWicate esBmated formatbn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE:
; , �lo Annular Space Exists
- _.. � ���: �`
� - ' .. ❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
in.from to k. ❑ Pertoraled ❑ Removed
in.irom �o ft. ❑ PeAorated ❑ Removed
Type of peAorator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
,-, , Y_ --.-y.. %i:
Grouting Material f'��� �-' ' "`� � �'-�rom i:% to �T tt. yards _,. bags
trom to h. yards bags
from to fl. yards begs
from to_— fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOH 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 ot my knowledge.
['��r� �'t�r�c,l� rdell �1r�llir��; ca. , Ir,c, 27172
Confractor Business Name .. License or Registration Yvo.
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�gr'ed Re¢rese�e Signature Defe
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. . ... . ,j�.i-:�- �.i�.�..-�'" ..-..i''
J ^���� Name ol Persar Sealing Well or Bonng�� �.
LOCAL COPY H „1.J