HomeMy WebLinkAboutwell info -- - -- MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 301273 ,�
WELL OR BORING LOCATION Sealing No. H
�o���Y Na�,e — WELL AND BORING SEALING RECORD Minnesota Unique Weil No.
Minnesota Statutes,Cha ter 1031 or W-series No.
P leava blank it not known)
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
�3 f
_ ,
GPS Latitude _ degrees_ __ minutes__. seconds Depth Before Sealing � ft. Original Depth ft.
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LOCATION: Longitude_ _ _ degrees ___ minutes_ _ seconds A �FER(S) STA71C WATER LEVEL
Numerical Street Address or Fire Number aAnd�City of Well or Boring Location �ingle Aquifer �]Multiaquifer � �nn.y�� �(��,/ �
4156 Ai�h�rood Rd, L�Cax} 5536�+ WELUBORING �Measured Estimated Date Measured___('Jl1 IC ►71 _ :
�Water-Supply Well ❑Monit.Well • t
Show exact location of well or boring Sketch map of well or boring
in section grid with"X." location,showing property .Env.Bore Hole ❑Other ___�� ft �below j�_',above land surface '.
' lines,roads,and buildirr11pps. � .s
N � � �� CASING TYPE(S) ".
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_
--'----'------`—- � ' '
Steel ❑Plastic ❑Tile ❑Other
- ,--- --�--- ---`-- ---'-- � ��,� WELLHEAD COMPLETION
. W ; : : ET ,� ��
� � � � Outside: [J Well House ❑At Grade Inside: ❑BasemeM Offset -
'h nniie �� ��itless Adapter/Unit ❑Buried ❑Well Pit _
� , � � ;
--�--- --�-- ---�----*— � ��
❑Buried
S ❑Well Pit
❑Other
�i Mile—� ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diameter � Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mai ing a ress if diHerent than well location address indicated above �� �—
�in.from � to�j_L ft. ❑Yes [�o i�'Yes ❑No ❑Unknown
__in.from to ft. ._'�,Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. �Yes ❑No ❑Yes ❑No ❑Unknown
i
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
Well owner s mailing address It diNerent!han property owner's address indicated above Screen from �J�to��ft. Open Hole ffom to ft.
OBSTRUCTIONS
�Rods,'Drop Pipe ❑Check Valve(s) [_�Debris ��Fill ._No Obstruction
YP ( 1� �� �.
T e of Obstructions Describe . /"_L./': .4._1,�� ___ . _ .. _ �
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es '��'No Describe
FORMATION --
PUMP t
If not known,indicate estimated formation log from nearby well or boring.
(� p Type
drift V OS ❑Removed �Not Present ❑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 if�l Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator____ _____ __
F„
�1 Other
�
GROU7ING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.)
�l M� ♦ c �
Grouting Material�/rl��1/�C�� from Q to �J 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 unsealed and unused well or boring on property? ❑Yes�No 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 true to the best of my knowledge.
Don Stodo2a Well �ri�Ilir�g CoT. Inc. 2692
Licensee Business Name License or Regishation No.
-�;�,��'��—`_ 1-1fr12
i R p e�en ative Signature-� Certified Rep.No. Date
301273 '�' �t°��
LOCALCOPY H __ _
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Name of Person Sealing Well or Boring
HE-01434-12 IC#140-0423 siosR