HomeMy WebLinkAboutwell info wELL OR BORING LOCAT1oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring F„I !"�����Q
County Name
WELL AND BORING SEALING RECORD Minne oNa Unique Well No. L ��
� Minnesota Statutes,Chapter f03/ or W-series No.
(Leeve denk H nol bwwn)
Township Name Township No. Range No. Section No. Fraction(sm-�Ig) Date Sealed Date Well or Boring Constructed
{?cono 118 2� 36 4#-()007,.
GPS �b�� degrees minu[es seconds � �
LOCATION: Depth Before Sealing ���ft. Original Depth ��_ft.
Longitude degrees minutes seconds pQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Locadon Single Aquifer ❑Multiaquiter
1 WELUBORING Measured ❑Estimated
� Water Supply Well ❑Monit.Well �
Show exact location of well or boring Sketch map of well or boring
in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other �ft. bebw ❑above land suAace
N � lines,r ,and buildings. CASING TYPE(S)
- - - - - -- - — `..��, +
Sleel ❑Plastic ❑Tile ❑Other
W -- - -i-- - -- --i— E WELLHEAD COMPLETION
� � � Outside: ❑Well House Inside: ❑Basement Offset
-;r- ---- -;-- -i--
, '� ' � �� �Pitless AdapterlUnit ❑Well Pit '
--;- -�-- -i-- --�-� r� .; - __
1 �.r✓ ❑Well Pit ❑Buned .
S
�—�,�.—�. �;�:,"��-�
❑Buried
PROPERTY OWNER'S NAME/COMPANY NAM�E�/ e� CASING(S)
�$'(� 76J�'F7�7�G Diameter Depth , Set in oversize hole? Annular space initialty grouted?
Property owner's mailing address rf difFerent than well location address indicated above �`
� in.ffom�_ to��ft. ❑Yes �No ❑Yes ❑No ❑Unknown
27Q5 Cty Rd 19
��s � ��3g9 in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
Well owner's mailing address if different than property owners address indicated above Screen from t0 ft. Open Hole from �/ / t0���ft.
c�i r
OBSTRUCTiONS
Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describ@�„��!t,ey�,� /'f��(��
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ NO D2SCflb2
FORMATION
I(not known,indicate estimated tortnation log hom nearby well or bonng PUMP �
d[ift Q 21 TyPe
Removed� ❑ Not Pres nt ❑Other
�$t(� �� 1 � 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 PeAoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
�'
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
/
Grouting Material�� ,��i ,T �""���—�to��ft. yards �� bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING 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 Rufes,Chapter 4725.The informabon contained in this report is
true to the best of my knowledge.
Ilon Stcx3ala 6�12 Dcilling Co, Inc. 27172
Contractor Business Name _ License or Registration No.
� ..... � :.% . � �~ !�lY"l)Y
.,- �. . _s- �� �,_
. o Re�resentahve SignaWre� Date
.T�.E1 �IiCOTl�[1
LOCAL COPY H 2 2 51_18 �
Name of Person Sealing Well or Bonng