HomeMy WebLinkAboutwell info ` wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„' � ;
Counry Name
WELL AND BORING SEALING RECORD MennlegoNa Unique Well No. s
H�C!?� �n Minnesota Statutes,Chapter 1031 or W-series No.
(�eave blank�il not known)
� Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Consiructed
Orvno 117 23 18 1 -flQEX;� Q
GPS Latitude degrees minutes seconds '� �
LOCATION: Depth Before Sealing ft. Original Depth_ ft.
Longitude degrees minu�es seconds qQUIFER(S) STATIC WATER LEVEL
`� Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
E L/BORING �easured ❑ Estimated
� Water Supply Well ❑Monit Well /
Show exact location of well or boring SkePch map of well or boring �/>
in section grid with"X" � , � roperty ❑ Env.Bore Hole ❑Other __��ft.�below ❑above land surtace
N �•�lines,roads,and uild}nxg`s.' CASING TYPE(S)
�teel ❑Plastic ❑Tile ❑Other
W -- - - -- - -- -- — E WELLHEAD COMPLETION
, ,
; r , � � � i � Outside: ❑Well House Inside:�Basement Offset �
-�-- -�- -;-- --�-- E �� :;
Ylmile � ❑ Piiless AdaptedUnit ❑Well Pit
'--- -i-' -1-- --�— �
❑Well Pit ❑Buried
S
�---"""° ❑Buried
�� �� � . �: _a_�T_ .= ' �-',�
�. PROPERTY OWN2E�R,'S NAME/COM Y NAME� CASING(S)
� iNi 952-471-9396 Diamete� � � Depth �� � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than wen location address indicated above � /
� in.from t0 ft. ❑Yes Il�1Vo ❑Yes ❑ No ❑ Unknown
��
,
- in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
4
in.f�om t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
'� WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � _
/
Well owner's mailing address it diflerent than property owner's address indic2ted above Screen from � YO�ft. Open.Hole from_ to ft.
OBS RUCTIONS
�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) �"�"`-'� ���� ¢ ���T��`�
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO Describe
FORMATION
If not known,indicate estimated formation log fwm nearby well or boring PUMP
T e
� �.:..� ::, `,j((� YP
❑ Removed �lot Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
rV� Type of perforator
❑ Other
� �TlrO GROUTING MA7ERIAL(S) (One bag of cement=94 Ibs.,o/ne°ybag of�ntonite=50 Ibs.)
QA, Grouting Material tN �T C���"—�Trom�to�..l3Q_ri. yards � bags
•�
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALWG 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 with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best ot my knowledge.
I1on Stodola �ell Drilling Co,. Inc. 27172 '
Contractor Business Name License or Registration No.
a
—�i'��Y—�--�'�"'� �,:. _ 1 � ..:i
� Authorized Repr sentative Signature Date .
��`....��, s
//�/�//� //� ` �i'-yy-._, ���,�,�;y'1�..4J'd1''�-
LOCAL COPY �7 i�L f��f�� Name o/Person Sealing Well or Boring . �