HomeMy WebLinkAboutwell info Minnesota Well and Boring 12 G�2 4 5 �
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o���Y Name WELL AND BORING SEALING RECORD M���eso�a un�q�e No.
�E'11[l+'].�i F; Mmnesota S�atutes. Chapter 1031 or W-series No-
ILeave blank il not known�
Township Name Townsh�p No Range No Section No Fradion�sm. �ly) Date Sealed Approx�mate Date Well
�^��F.�V��.e i.;t-[� 1 1�I\ ��i i4 �l+J i���j L����,7 L'1�� t};f t_` �j �r i� or Boring Construc�ed
Numencal Street Address or Fue Number and Gty of Well o�8onng Location
%�� 1'E.'��rlCtcilf' P.�1$� tYClY��1l DepihBeforeSealinq --.— ��.�—� it. OriginalDepth ft
Show exac�locahon of well or bonng Sketch map of well or bonng S�ahc Water Level ��Accurale
in seclion gnd with��X�. locahon.showing property hnes.
roads.and buildings. ❑Approxima�e -
N
i i i i _._._.`'
-- -;- -;- --
� ' � �Single Aqwfer ❑Multiaqwfer ft below above land surface
i i i i
-'- -�- -�- -�- � CASING TYPE
W i i i i E �
i i i i T ; . .. . 1. _ .
__ _�_ _r_ _�- T � ;
� i i � � �S�eel ❑Plashc ❑Tile ❑O�her
� -mile i
i i i �. ' � 1 �,. . .. .
__ ___ __ '
i i i - �. �, ��
S i � �, � Screen from to ft. Open Hole irom to ft.
N--imile—�I � �' . OBSTRUCTION/DEBRIS/FILL
,R.QP Yyy� �Obstruction ❑Debris ❑Fill
P!'; 1�t�TY�1 t RS.NAME � y r-. 1 . .
"► .
. �..-t. �. . . ,�"i _ ', �
Type of debris/obstrudion
Mading Address rf diNeren��han propehy alddress indicated above.
Obstruction/Debris/Fill removed? 0 Yes ❑No
�`:..�:}'I:�L�I�I��afi� : ri�SiL�� PUMP
�.� �c�I'nd�lf. f;. ;:�-j !�(t,l� i: ' ._� ' _ ,. .� _ .! .. �{ . + 1 � t_ ��: . . .
��ctti".�%t�._k , �'��L � _���}1 �Removed ❑Not Presenl ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diarneter. . . Depih . Se�in overs�ze hole9 Annular space initialty grouted�
If not known,indicate estimated formation log Irom nearby well or boring. , , „ �.► _, j :,
in.from to it. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown -^
in.irom to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown ��
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
[']No Annular Space Exisis
❑Annular space grouted with iremie pipe
❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑O�her �
GROUTING MATERIAL
�r' — 17
Grouting material from to fl. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. — yards bags
I�` 1 �..�.�. � _ cF'� it'ti_�1' � i..��;3 �. -.� f - _ t
.., ;.'..f.� .. ;�' t:' .'f '.. . . . from to fl. yards bags °
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 information contained m ihis report is
true to the best of my knowledge.
`�_� t �,:r���. -,;_'_;"l'i:R ;;EF�i' i ,_ �, �.
Contractor 6usiness Name � // �//l�Cense or Registrat�on No.
i � t:,a } — t,y 6.�- { .E`f` �; i/'� j . . _
. .. � ' � i -�_ � - { { ' { S�� ��'�..:��. �.�1 _1 i t'. ri ' . _
j ' i. I �,,,��-'�.-.
i 1'.#��.�.s f r jl �� 1{ ! } � - ,_, , Authonzed Representative Signature { Da�e
'�+ T��.�I4 �"�<.t��_Cii>.�'
LOCAL COPY H 2 0 2 4 5
Name of Person Sealing Well or Boring
HE-01434-01