HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 6 514
WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No.
Councy Name Minnesota Unique No.
F..ennepin Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank if not known)
Township Name Townshi No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
orano li�i 23 i7 2;no�7 ,, 2� J� �
N{��jri Street Address or Fire Number and Ci of ell or nBoring Location � �
1!� Fa;erness P� ��� VrfllfO Depth Before Sealing l� � ft. Original Depth � � � ft.
Show exact location of well or boring Sketch map of well or boring UIFER(S) STATIC WATER LEVEL
in section grid with"X". ,t location, showing property Single Aquifer ❑ Multiaquifer
� w�� lines,roads,and buildings.
N _�..----- WELUBORING �Measured ❑ Estimated
� � � Water Supply Well ❑Monit.Well ,
- -;-- --;-- �!�'
� ❑ Env.Bore Hole ❑Other 7 -' ft. �below ❑ above land surface
__f_ _l__ _l__ __l__ 4..__f_
yy E � CASING TYPE(S)
� � � �
� � __�_,._,
� � � � __—'--
--�- -�-' "�-- --�-- �Steel ❑ Plastic ❑Tile ❑ Other
;c mi�e
--�- -�-- -�-- --�-- � - CASING
� � � � ,�+. `�^� ���` Diam tef� Depth . � Set in oversize hole? Annualar space initially grouted?
l� S """��,��� ___-
µ—i m��e--qe . in.from � to f� -' ft. ❑ Yes �Alo ❑Yes ❑No ❑ Unknown
I I
P�O�nO NER'S NAME � in.irom to tt. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown
�e�son G71-o3s1
PropeAy owner's mailing address if ditterent than well location address indicated above. in.from to ft. ❑Yes ❑No ❑ Yes ❑No ❑ Unknown
$t tn:.Tenny Hewson SCREEWOPEN HOLE
� ,
Screen from �4-` to L',�� ft. Open Hole from to ri.
file�971G�431
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owners mailing address if tliHerent than property owner's address indicated above. Type of Obstruction/Debns/Fill _.�NNf�l / -=�/""�'� `�` 1` Ur��
Obstruction/Debris/Fill removed?�Yes ❑ No
PUMP
�y�� 'c`j L�� ��1,������
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ PeAorated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
r
%Lf-,J i.!r�/f��.t.�
Grouting Matena�� from � to /� ft. yards / � 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
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is
true to the best of my knowledge.
Don Stodola W�11 Dril2ingCo., Inc. 27272
Conhaclor Business Name � License or Registration No.
✓ � ''�
�.. ,� � ��
�i'���'1 I
Autho zed epresentative Signature - Date
Jim Antonson
LOCAL COPY H 12 6 514 Name ol Person Sealing Well or Bonng
HE-01434-02 10/95R