HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I ������ �
Counry Name
— WELL AND BORING SEALING RECORD Minnesota Unique Well No. ICH— - �
Minnesota Statutes.Chapter 1031 or W-series No. �
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Township Name Township No. Range No Section No. Fraction�sm.-i Ig) Date Sealed Date Well or Boring Const�uctetl
�rono 11? 23 20 ' ' a 9�
Numencal Street Address or Fire Number and Gry ol Well or Bonng Location r �
274d 8the1 A��'• y�(�nQ �5.7�� Depih Before Seal�ng���_R Original Depth ��� n
Show exact location of N•ell or bonng Sketch map of well or boring AOUIFEH(S) STATIC WATER LEVEL
m section gnd wrth"X". locahpn,.. showing property Smgle Aywfer � Mulhaqwfer
�,�„�y,�lineslJo�,�ui Idings.
ry -- -- ---- WELUBORING �Measured ❑ Esamated
�Water Suppry Well ❑Monit.Well �h r
❑ Em.Bore Hole ❑Other �R I�below ❑ above land surface
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7�
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W --r- -�-- -'-- --'-- E CASING TYPE(S)
—�- ---- -i-- --�-- � Steel � Plastic �Tile �Other
}1milB ��
—�- -j-- -�-- --j— � -- CASING(S)
Diam ter Depth � Set in oversize hole� Annular space initially grouted?
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�r mi�e� �`�� � in.from v' to�+L� tt. ❑ �es (�No ❑ Yes ❑No ❑ Unknown
PROPERTV OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
Lance Yickna -
Properry owner's mailing aAdress d diHerent than well iocanon address mdicated above m.from to fl.. ❑ Ves ❑ No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN MOLE
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Screen from J�3_S.�to�L� fl. Open Hole from to R.
OBSTRUCTIONS
WELLOWNER'SNAME . �. �'.�� ���-- ��� �Fods/Dro Pi
p pe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstructiofn'�
Well owner's mailing address il ditterent than property owner's address indicated above. Type of Obs�ructions(Describe)�/�[1`�/e • �=�� � • ���
Obstruclions removed? �Yes ❑ No Describe
PUMP .
TY� Su8 Pu�'tp
GEOlO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
• FORMATION
If rat known,iMicate eslimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OH CASING AND BORE HOLE:
j � �No Annular Space Exists
V
❑Annular space grouted with tremie pipe
❑Casing PeAoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to tt. ❑ PeAorated ❑ Removed
Type of peAorator
❑ omer
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) .
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Grouting Matenal /������11G/`�Nom � to�3� tt. yards • � bags
from to R. yards bags
from to fl. yards bags
irom to__ R. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property7 ❑Yes No How many?
� LICENSED OR RECa1STERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in Mis report is�
true to the best ot my knowledge.
Dan S�odola �Te21 Drillinq Co.� inc. 2' �
Contrador Business Name � �lcense a Regis'
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i yi:�? �S3P� u �C�V C� Name ol Person i Well or Boring
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