HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring �„I \� � �� ��� �
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes,Chanter 103/ or W-series No.
� Y (Leave blank�il not known�
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
� T A �� � S
GPS LOCATION-decimal degrees(to four decimal places) �
Depth Before Sealing�__ft. Oriqinal Depih ft.
Latitude__ _____ ___ Longitude__ `
IFER(S) STATIC WATER LEVEL OF O
Numerical Street Addre-sNs or,,,F,i�re Number and City ot Well or Boring Location Single Aquifer IJ Multiaquifer �� .A�L/
1(�5(� �',(��(.swtJlX:.t ��3�.'�e3 �� ('�rO�TA '� �VBORING �Measured [ IEstimated DateMeasured_ �3 1
ater-Supply Well !_-!Monit.Well Q ♦
Show exact location ot well or boring Sketch map of well or o�i �,Env.Bore Hole �C� �b (:1 above land surface
in section grid with"X:' location,showing prop rt� � ❑Other ,_.ft. elow
lines,roads,and buildi gsj
N ._,___..._ ��-, CASINGTYPE(S)
r.�.� �a
-_ -_- ---'-- --- _-_ ' � Steel '��]Plastic ! �Tile �I�Other —---_ — ___
'�� WELLHEAD COMPLETION
� W ' ' ' ' E T h t d II H t G d I d . � asement Offset
; ; � � I �—� S`�� Ou si e: , ;,We ouse �J A ra e nsi e• �]B
-F----%- �� ,,,���///
; ; ; , 'h M�ie �Pitless Adapter/Unit �Buried ❑Well Pit -_
Buried F
--�-- '-�-- -�- --�- � � LJ �,
S � w��- . I Well Pit ,..
t�
�Other
�—1 Mile� ��� .�R ', �:OfhBf _ �
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� Diam er� f Depth � Set in oversize hole? Annular space initially grouted?
i
Property ownei's mailing address if differeni than well location add�ess indicated above �in.hom� to.��_ft. ❑Yes I�No `!Yes �__�No [__Unknown
Z��1� ���n�t0� .J1� in.from to ft. ��,...!�Yes I�_�No ']Yes [_�.No ❑Unknown
� r+�T 55391.
in.from to ft. ��Yes � 1 No ❑Yes [J No n Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � �+ �
Well owners matling address If dltierent than property owner�;address indica�ed above Screen from___I ��__to_ ���✓ ft. Open Hole from to __.__ft.
OBSTRUCTIONS
�Rods'Drop Pipe ��Check Valve(s) ❑Debris ��;Fill �No ObsVuction
Type of Obstructions(Describe)_����.___../ .�-I-'.�-__ 9" ��. ��
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes I_j No Describe_.
FORMATION
' PUMP
If not known,indicate estimated formation log from nearby well or boring. U °
.� D /� TYPe�----�� ----- �.
!�emoved ��, f Not Present '�,_]Other _ _
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� �No Annular Space Exists .-]Annular Space Grouted with Tremie Pipe �,__Casing PerforatioNRemoval
� in.trom __ . to______.___ _ft. i,�Perforated ;_'�Removed
i i�
,,_� ,r- � _. _ In.from to__ ft [�Perforated � J Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for ihis well? ,_,'�.Yes ��No TN# ._ _
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
/�� � /� f
GroutingMaterialN'�AJ(�/�rfrom__V r__ to_��� ft.____ __ _ yards_�� bags ��
from__ to ft. ___ yards bags
from,___ to ft.______ _ yards_ bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealedand unused well or boring on property? , Yes � o How many?___,__ _____
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �
This well or boring was sealed in acwrdance with Minnesota Rules.Chapter 4725.The information contained in this report
is true to the best of my knowledge.
?�cm �torlola �Iell Dci1li�Co�. In_c__.___1691 _ �
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Licensee Business N� e i License or Registration No.
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��R res ntative Signafur � Certified Rep.No. Date
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LOCAL COPY 3 3 3 0 7� Name o/Person Sealing Well or Bo�ing �
HE-01434-14 IC#140-0423 . S-i3R