HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 31�614
County Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No.
f��e��� Minnesota Statutes,Chapter 1031 or W-series No.
(Leave bl�n+il nol known)
Township Name Township No. Range No. Section No. Fraction(sm.�ig.) Date Sealed Date Well or Boring Constructed
Qconr� 117 23 07 �F �E � f C� D EC /2
GPS LOCATION—decimal degrees(to four decimal places) �J �
Depth Before Sealing `� ft. Original Depth ft.
Latitude Longitude
IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and Ciry of Well or Boring Location ! _Single Aquifer �_'�,Multiaquifer e�-t� /��
4148 Ft�f,�hwnod Rd, Or�o �'/ LUBORING [�vleasured �J Estimated Date Measured Jn mt !J/'��
�Water-Supply Well [�Monit Well r �/ �
Show exact location of well or boring Sketch map of well or boring �.i • '��]u �above land surface '
in section grid with"X" location,showing property � ,Env.Bore Hole ��Other__ � ___ tt. L below
N � { lines,roads,and buildings. CASING TYPE(S)
--:._- --�_. ---`-- ---'--
� �,Steel [;Plastic �,_Tlle �, �,Other
---- -'-- --- -- ----- WELLHEAD COMPLETION
' - -I. : :
W __ ET �
�.,. � Outside: ,__j Well House � �At Grade Inside: �asement Ottset
� � � � �� � �� ' I A /� � � uried ��Well Pit
i �
� B
; ; � � . �,_ �Pit ess dapter nit �
�-- � 5—�- -�-- I�.7� �
, , ; ; '. - . ;Buried `
�y ��- �j [.�Well Pit �.:
� i Other_
�-1 Mile-� �.�.�OthBf_ � � �
\ __
P�{9gERTY�O 9NE NAME�COMPANY NAME CASING(S)
1"'l�a••"`.' ��Cer Dia te�r� � Depth � Set in over�s�ize/hole? Annular space initially grouted?
Property owners mailing address if ditterent than well location address indicated above ,� jn.from� t0 �� ft. '�Yes �_I{IJo !r]Yes I_'.NO LJ Unknown
P.O. 13osc 763
•�81Zf�t�n �t�Ay� �, �AT� in.trom_____ to ft. _,Yes '-!No �.'j Yes ❑No ❑Unknown
J
in.irom to ft. 'Yes �__;No Yes '
,__. �] ❑No l]Unknown i
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE �
i
Well owner's mailing address if different Ihan property owner's address indicated above SCfeen flom� to_ �� ft. Open Hole from to.,__ ft.
OBSTRUCTIONS
�Rods/Drop Pipe �_'i Check Valve(s) ❑Debris �,!Fill ❑No Obshuction
Type of Obstructions(Describe) 1��'fI�__ ��r � � �(.��J �T�,✓�j�
GEOLOGICAL MATERIAL COLOR HARDNESSOR FROM TO ObsVuctians removed? �es ;__�No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
� ` YP �
'��'-`� `�`� f�f� f� Removed �Not Present [�Other
r METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: °
- � j�Jo Annular Space Exists �_]Annular Space Grouted with Tremie Pipe `Casing Perforation/Removal
in.from __to ft. �'�Perforated i.�Removed
in.from __ to tt. �L]Perforated [-]Removed
T e o!Perforator
VARIANCE
Was a variance granted from the MDH for this well? �._j Yes ❑No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
,.�+ g''' r /-�+
GroutingMaterial�'L��� c.._-�-��-J��from � to /7 fl.___ _ _ yards� bags
_ from____ to ft._______ yards bags
____ .. ___ from___.___ to_ ft. yards bags
OTHER WEILS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? []Yes �jo How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This wetl or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge. .
I� Stodala Well Drillin� Co,. Ine. ��,9L__
Licensee Busin ss Name � - License or Registration No.
� ,- � /� //'-/..3
ified es�n t e Signa Certilied Rep.No. Date
. ::.. _�..�.. �.�.���'�.�..`�._
LOCAL COPY H � '� �j`� ��
--—— ...----
�J� Name ol Person Sealing Well or Boring
HE-01434-14 IC#140-0423 sn3q