HomeMy WebLinkAboutWell Sealing Record �
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ���r��� �
WELL AND BORING SEALING RECORD Sealing No. H ;�
Counry Name Minnesota Unique Well No. —
Minnesota Statutes,Chapter 1031 or W-series No. � I
�i�nnep i n �.�,.d,�„�k�.,,, _J
Township Name Township No. Range No Section No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Construdetl
�rono 117 23 07 k4-0�l3 ''f Uit„i� C�/
Numerical Street Address or Fire Number and City of Well or Bonng Location �
4101 Highwood Bd, flro�o P 9-_��— 9 P '`�
De th Before Sealin R On inai De ih _i N
Show exact locafion of N�ell or poring Sketch map of well or bonng Aqy11FER(S) STATIC WATER LEVEL �
in section grid with"X'. location, show+4(,� propeny D�Single Ayuiter ❑ Multiaquder
{ � ,� lines,ro s,and�puil gs
N �"'S _ :-�_������� '1� � WE�UBORING Measured ❑ Estimatetl
�cj Water Supply Well ❑Monit.Well �
� ❑ Env.Bore Hole ❑Other _ _ �� ft. �below ❑ above land suAace
W --�- -i-- -i— —i— E � CASING TYPE(S)
� � � `h,
\
-;-- --;-- -;-- --�-- � �,}g'r Steel ❑ Plastic �Tile �Other
Ylmile
—�- -i-- -�-- --�-- I CASING(S)
� Diamete j� Depth /`. � Set in oversize hole7 Annular space initially grouted?
� S � 0 �v Yes �No Ves No Unknown
i miie� m.from to fl. ❑ ❑ ❑ �
PROPERTV OWNER'S NAME m.irom to fl. ❑ Yes ❑Na ❑ Yes ❑No ❑ Unknown
Y
Propeny ownei s maili g address if d erent t n well location address indicated above. m.hom to ft. ❑ �es ❑No ❑ Yes ❑No ❑ Unknown
'�f'f 1� Sho re 1 i ne Dr SCREEWOPEN HOLE �
S�ring Park, MN 55384 ' �c
9 5 2-4 71-fl 5 32 Screen from�l��o� ft Open Hole from to n.
oesrRucnoNs
WELL OWNER'S NAME � Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction .
Weil owner's mailing address if diflerent Man properry owner's atl0�ess mdicated above. Type o(Obstructions(Describe)�-i'�'�G�"! ����✓ g ������``"���
Obstructions removed? �Yes ❑ No Describe
PUMP
TY� r,`► (�'G K,_r �(,+l� �
GEOLO(iICAL MATERIAI COLOR HARDNESS OF FHOM TO �Aemoved ❑ Not Present ❑ Other
FORMATION
If not krawn,inOicete esGmeted formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� (� �.No Annular Space Exists
{.__ t.�. i� ..i 7
❑Annular space grouted with tremie pipe
`�� ❑Casing Perforation/Removal
in.from to ft. ❑ Pertorated ❑ Removed
in.from to n, ❑ PeAorated ❑ Removed
Type of pertorator
❑ Omer
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
.�..�- �
Grouting Material ��������NlFom � to� ft. yards � bags
from to ft. yards bags
from to ft. yards begs
from to__ fl. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes No How many7
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The intormation contained in this report is
true to the best of my knowledge.
Don Stodols Well Dri33fag Co. , Inc. 27172
Contraaor Business N me Liaense a Regishalion�10.
� - 1� � �
m ed ePrese�rerrve s�y�erure- oere
./`v". . ,._ `..y�,,,�./! st:„� 4 ,.f'�-.��`Y�"e�
H w /ti/���n Name o!Person SeaFng Well or Boring
L 7�'�i.i:e�;�,.�, f s j�.� V