HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 4 9 6 3
Counry Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique No.
Minnesota Statutes,Chapfer 1031 or W-series No.
(Leave blank it not known)
ow s p Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
� 'e '/a
Numerica treet Address or ire Number an ity oi e 1 or Boring ocation � �
r, Depth Before Sealing ��Sp ft. Original Depth �"S�_ft.
Show exact location wel or bo g Sketc map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X". j location, showing property Single Aquifer ❑ Multiaquifer
t lines,roads,and buildings.
N � WELUBORING ❑ Measured i�Estimated
Water Supply Well ❑Monit.Well
7�
_T_ __l__ __l__ � �
I i � � ' �i
❑ Env.Bore Hole ❑Other ft. elow ❑ above land surface
__r_ _Y_ _l__ __l__
yy E /�/,j CASING TYPE(S)
--�- -r- -�-- --�-- � � Steel ❑ Plastic �Tile ❑Other
Y mile
-�-- -�-- -�-- --�-- � ,._�_.�.._.,, �;.�....��c.�� CASING
� S � �� � Diameter,' Depth � Set in oversize hole? Annualar space initially grouted?
lll""" ""�J�� i •-T'-'-'.�_ �,,('
�w--i mi�e-�e +`/��.;;;i;+ � � in.from� to��. ft. ❑ Yes �IVo ❑ Yes ❑No ❑ Unknown
I I f � T�
PROPERTY OWNER'S NAME _ in.from to ft. ❑ Yes ❑ No ❑Yes ❑No ❑ Unknown
�o o ner' ddress if different than well loc o� ad e s n icated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑No ❑ Unknown
1 Ot Z SCREEN/OPEN HOLE
Screen from��to , ft. Open Hole from to ft.
08 S T R U CT I O N/D E B R I S/F I L L
WELL OWNER'S NAME �Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address it difterent than property owner's address indicated above. Type of Obstruction/Debris/Fill ��r(1/tJ«T�f-1'" �. /"r!J/yJ/'-�
Obstruction/Debris/Fill removed? Yes ❑ No
PUMP
Type�/Ji�r�/�1�
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�/fJo Annular Space Exits
; a
LJ�Annular space grouted with tremie pipe
`� ❑ Casing Perforation/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft, ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
/
Grouting Material v p from �_ to 1�� ft. yards �� bags
i��,w
from to ft. yards bags
from to ft. yards bags
from to R. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ Yes o .
LICENSED OR REG�STERED CONTRACTOR CERTIFI AT ON
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.
Conf�actor usmess ame License or Registrati .
�,.�' � IVl - __.._ ''_ ' _. , .
�i�� : � � �j . �. „� ����
o e resent2��S�gnat� Date
._._....r^^" .
. `�c."`.".
�y Name vf P�rson Sealin Well or Borin � ��''c ' , 4.
LOCAL COPY H f 0 t�. � � � 9 9
NE-01434-02 10/95R