HomeMy WebLinkAboutwell info WELL OR BORING LOCATtON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bonng i H �.4�0 7 3�
WELL AND BORING SEALING RECORD Sealing No.
Counry Name Minnesota Urnque No. — —
Mmnesota Statutes,Chapte�1031 or W-serles�io. �
I�eave dank A rw�known�
Township Name Townshlp No. Range No Section No. Fracuon�sm.-s Ig.) Date Sealed Date Well or Bonng Constructea
! � .�Uv �;'
Numencal Street Adtlress or Fire Number and Ciry o1 Well o�Boring Lowfion �/ /
Depth Betore Sealmg f��� N. Onginal Depth �J� it.
Slww exacY locatwn of w•el�or boring y* Sketch map ot well or bonng AOUIFER(S) STATIC WATER LEVEL
in sectan gnd wiM'X'. ��� location, showing property Single AquAer �Multiaquder
lines,roads,and bwldmgs.
N � WELUBORING Measuretl ❑ Esnmated
,i ,� I Water Suppy Well ❑M«,u wen �
- - - - - -- - -- ,� � �''
.� t �1` � ❑ Env_Bore Hde ❑Other �+_�R. �below ❑above land suAace
W - - - - - -- --i-- E }`?- � CASING TYPE(S)
� � � � �
-;r- -�-- -�-- --�-- �` � Steel ❑Plaslic ❑Tile ❑Other
;�mrle;,.
--�- -�-- --I-- --i-- � . ` CAStNG
� Diameter Depth f Set m overs�ze hde7 Mnualar space inAialy grouted?
��
�—r� � m.rrom � ro�r n. O ves �na ❑ ves p No O ur�nown
PROPERTY OWNER'S NAME m.tram to fl. ❑ Yes ❑No ❑Yes ❑No ❑Unknown
�
Propeny owners maiNng ress il diflerent than well location address indicated above. in.ham to fl. ❑ Yes ❑No ❑�'es ❑No ❑UNuawn
SCREEWOPEN HOLE R,
� /j
saeen rrom � l ro /r• � e. oper,r+o�e norn to x.
OBS7AUCilONS
WELL OWNER'S NAME R Chedc Valve(s) ❑Debns
ods/Drop Pipe ❑ ❑Fill ❑No Obstniction
� ...—
WM ow�iefs msikg address il tlilfefent Man property owner's address indicated above. Typ6 ot Obstructions(DesC�b6)���''�'�f� �!.�/'C �`'-' . f F�
Obsirucdms removed? �Yes ❑No Describe
PUMP
Type �
(iEOL.0OICAL YATERIAL COLOR MARDNESS OF FROM TO �Removed �Not Present ❑ Other
FORMATION
tl na1 krawn,indiceb estimaroG tamatqn lop from nearby wen or bonng. METHOD USED TO SEAL ANNULJIR SPACE BE7'VUEEN 2 CASINGS,OR CASING AND BORE FiOLE:
._�j • r- F � '_' `4 ., No Mnular Space Exi1s
Y
❑ An�ular space gauted wBh tremie pipe
{ ❑ Casing PBAorationlRertaval
in-horn to fl. ❑ PeAaeted ❑ Renaved
in-Irom to R. ❑ PeAweted ❑ Rertaved
Type o(peAasbr
❑ Olher
GROUTNiG MATERIAL(S)
T / ,/
Gra,engMarerial itii=,�%c'"'�,+1 J/.–�.�4i6m S,� w `��� n. yards �("L bepa
hom to ft. yards 6a�p
hom to h. yard4 beps
from M__ h. Ya�ds D�ps
NEMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORMIGS
Olher unsealed and inused we�a boring on propert� ❑Yes No Fbw many?
LICENSED OR REGISTERED CONTAACTOR CERTIFICATION
This weM w borirg vras sealed'n acoordence wilh MinnesWa Rules,Chapter 4725. The irHamation oorNained'n tlis raport is
tnie to Me best d my lawwbdye.
Don Stadoia W�11 Dril3ing Co. , Inc. 27I72
connado.9us:�Mame �, ,.) � Licenss w Repie6aem r••o.
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LOCAL COPY H 3,4�O?3 ��a Seaig WeI d Bonrg
HE-01434-03 �R