HomeMy WebLinkAboutwell info wELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i �Q���� �
ry WELL AND BORING SEALING RECORD M;��'ego a u��q�ewe��No. iCH_ p — �
Coun Name
Minnesota Statutes,Chapter 1031 or W-series No.
Hennepin h.�.a.���,k�,
Township Name Township No. Range No Secfion No. Fracuon�sm.�Iq.) Date Sealed Date Well or 8oring Constructed
4rano 117 23 17 2�3-�02 �- pC ,-
Numencal Street Adtlress or Fiie Number and City of Well or Bonng Location
18�7 Fagexness P� Rd� �rQn� P 9 �� ' 9 P �� ' h
De th BefOre Sealin � fl. Ori inal De th
Show exact locatwn of N•ell or boring Sketnj�map ot well or bonnq AOUIFER(S) STATIC WATER LEVEL
m section grid wi�h"X". �� �Iqg�bn, showing property y�9�Single Ayuder � Multiaquifer
-, lipes,roads,and buildings
ry ;' j `•.� WEWBORING Measured ❑ Eshmated
, � � � � �, Water Supply Well ❑Monit.Well �
� � "�_' '_i `
` ❑ Em.Bore Hole ❑Olher _ _�R. [�below ❑ above land surtace
W —�- -i-- -i-- --i— E .� CASING TYPE(S)
� � � �
� �
� � � � /
` --�- -�- -i-- --i-- C t
, y Steel � Plastic �Tile �Other
� � � � �� ,. , .
_ -�-- -�-- -�-- --�— � �/ i 1� CASING(S)
�Z~ Diameter� Depth � Set in oversize hole? Annular space initially grouted?
LL�� S
�(�—r mire� � � t/ in.from � to ��� tt. ❑ Yes �lo ❑ Yes ❑No ❑ Unknown
I i T�
PROPERTY OWNER'S NAME , m.from to R. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
Property ownei s ailing addres f different t�an wel ocation a ress indicatad above. in.trom to R. ❑ Ye5 ❑No ❑ �es ❑No ❑ Unknown
7�2�"t71-0490 SCREEWOPENNOLE �
� �
Screen from ��� to ��S%� ft. Open Hole from to R.
OBSTRUCTIONS
WELL OWNER'S NAME �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owners mailing eddress if ditterent than properry owner'S address inAlcated above. Type Ot ObSt�uCtionS(DescribB) �111/tJrG`� / S-�� Q'" ��Jm/
Obstruclions removed? �1'es ❑ No Describe
PUMP
TY� �c4� i%�rn f�'
OEOLOl31CAL MATERIAL COLOFt MARDNESS OF FROM TO Removed ❑ Not Present ❑ Othe�
FORMATION
N rat krawn,indicate estimated formatbn log trom nearby weli or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANO BORE HOLE:
� - k �(Jo Annular Space F�cists
r`` �,a � ''�
❑Annular space grouted with tremie pipe
,�, ❑Casing Perforation/Removal
in.from to k. ❑ Pertorated ❑ Removed
in.irom to R. ❑ PeAorated ❑ Removed
Type of peRora[or
❑ Omer
GROUTiNG MATERIAL(S) (One bag of cement=841bs.,one bag of bentonite=50 Ibs.)
Grouting Material 3N�� '���"fr6m � to� tt. yarAs f[_ bags
trom to ft. yards bags
trom to R. yards begs
from to__ R. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wiM Minnesota Rules,Chapter 4725. The information contained in Mis repoR is
true to the best of my knowledge.
Don Stodols Well Drf2ling Co. , inc. 27172
Confrador Business Name � _ Licerrse a Regisfreh'on Cio.
�, - .
__ - ,� � �fr� ,�� ..� i
o�ed resentetive Signafure' Date
�.� _ _ � �.i�. ./,iJS'`!�_
���A�.���v H 18 5 9 3 0 Name o/Person Sealing Wel/br 9ori�