HomeMy WebLinkAboutwell info Minnesota Well and Boring 2 8 919
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o���Y Nam� WELL AND BORING SEALING RECORD M���esota u��q�e No.
����n Minnesota Statutes. Chapter 103! or W-series No.
�Leave biank il noi known)
Township Name Township No. Range No. Section No. Fraction(sm �Ig.) Date Sealed Approximate Date Well
O�� ��� qg� � C{,'il�r 'Cy,r /' p'�C f(�� or Bonng Consiructed
Ld Jw ,�K ���I O {7(7
Numencal Sireet Address or Fve Number and Cdy of Well or Boring Location
ZJ�� F�x ,��',��t �}"(�� Depth Before Seahng ��� ft Onginal Depih ft.
Show exact locahon of well or bonng Sketch map of well or boring Static Water Level �Accurate
in sec�ion grid with��X��. loca�ion.showing property lines.
N roads.and buildings. ❑Approximate
i i i i
_i_ _-_ ___ _i
�Single Aquifer ❑Multiaquifer ft. X below above land surface
i i i i
_i_ _�_ _i_ _i_ CASING TYPE
W i i i i E
� � � � T
_i_ _r_ _�- T ,�1t
� � � � � LTSteel ❑Plastic ❑Tile ❑Other
i.mile
_i i i i_ �
I I I I
S Screen from to ft. Open Hole from to it.
N--i mile--�I OBSTRUCTION/DEBRIS/PILL
PROPERTY OWNER'S NAME ❑Obstruction ❑Debris ❑Fill
8ett stinson
Type of debris/obstruction
Maihng Address d differen�than property address indicated above.
Obstruction/Debris/Fill removed? ❑Yes ❑No
134� fox Street PUMP
Orono, ���N 55391
�Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log trom nearby well or boring.
� in.from to ft. ❑Yes ❑No ❑Yes ❑No �Unknown
in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�No Annular Space Exists
❑Annular space grouted with iremie pipe
❑Casing Pertoration/Removal
in.irom to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
Grouting material �at C�L�t from ��to �_ft. yards �_bags
from to fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
House has been soid. 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 Minneso�a Rules,Chapter 4725.The inbrmation con�ained in this report is
true to the best of my knowledge.
Stevens Well Dril'ltn� Co. lnc. �7194
Contractor Business Name ' License or Registration No.
�; s� .r,'����� '� 8/26./93
� 1�,�'�.�,.q..,,,� �„�;,� �
Authorized Representative Signature � Date
LOCAL COPY H 2 g 919 TQ� S'�Y@{1S
Name ol Person Sealing Well oi Boring
HE-01434-Ot �