HomeMy WebLinkAboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and eoring H �O�Z�O
County Name
WELLAND BORING SEALING RECORD MnnlesoaoUniqueWellNo.
Minnesota Statutes,Cha/�ter 1031 or W-series No.
�� �"' (Leave blank il no�knOwnl
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Orano 117 23 20 NS NW 1� Z
p .
GPS Latitude degrees minutes seconds Depth Before Sealing �p ft. Original Depth ft.
LOCATION: Longitude degrees _ minutes seconds A UIFER(S) STA71C WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location . ingle Aquifer �Multiaquifer t!
WELUBORING I�leasured ❑Estimated Date Measured �lTf/� Q/9�
� �Nater-Supply Well ;J Monit.Well /� .
Show exact location o wel or boring Sketc of well or boring /Z• h. '`',��..below '
in section grid with"X." lo n,s wing property Env Bore Hole �]Other __ ;�above land surface
N \ es.roads, nd buildings. CASWG TYPE(S) �
� �
s
--'----�— --`-- '_''- ..
�.�teel . �;Plastic r Tile �_;Other ___
W __ _________ ' ' _ E /S�
WELLHEAD COMPLETION
__�_____;____;__ ___;_ � �y Outside: [�;Well House ❑At Grade Inside: ❑Basement Offset
�M� L� ��itless Adapter/Unit ��Buried ❑Well Pit
, , , , 1
--�-----�--- ---�-- --�— ❑Buried �'
5 � ;Well Pit
�v ❑Other
F--1 Mife� �� � .,Other
PRO�PE`RT�Y OWN*E�R'S.,.N�A,ME'COMPANY NAME CASING(S)
uLi1t� t�CwL{M Diam ter Depth ' Set in oversize hole? Annular space initially grouted?
Property owner's mailing address it ditterent than well location address indicated above +•in.from_� to��ft. ❑Y@5 [�Jo ❑Yes ❑NO ❑UnknoWn
in.from to ft. ❑Yes '_,'No ❑Yes ❑No ',_]Unknown
in.from to R. �;J Yes ❑No ❑Yes ❑No j_J Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner�s mailing address ii different than property owner's address indicated above SCfeen frOm_��_to �S1 r ft. OpBn Hole from tp ft.
OBSTRUCTIONS �
�tods/Drop Pipe [;Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)_ ,i�II�,V�It /'�� } / (//��
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions remaved? es
FORMATION ❑NO DBSCfibB
If not kn wn,indicate estimated formation log from nearby well or boring. PUMP
.. r �,- TYPe Sv� � u m p .
�emoved _Not resen[ ❑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 €
= Type of Perforator
L
L���f10f
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag ot bentonite=50 Ibs.)
/�� r�G r
Grouting Material.�I�r/ ��,r`�r�J�from �' to_S_� R. yards� bags
from to ft. yards _ bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [_I Yes o 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 hue to the best of my knowledge.
Don Stc�dols_Well Dti12 Co.�Ir�. 1691
Licensee Business License or Registration No.
- .� --'"" � ' � �I- �v�...
Ce �e epresentativa; gnature Certified Rep.No. Date
LOCAL COPY H
306210 � ,` ~ .--�"'��`..�� --
�N a�me ol Person Sealing Well Bonng
HE-07434-12 IC#140-0423 4 siasR