HomeMy WebLinkAboutwell info Mmnesota Well and Boring 1217 5 3
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o���Y Name ,I WELL AND BORING SEALING RECORD M���esota u��q�e No
y�, �t^ Mrnneso�a Sta�utes. Chaptei 103/ or W-series No.
� � I�eave blank if not knc�wn)
Tow iship Name Township No Range No Sec�ion No Fradion�sm. �Ig) Date Sealod Approximate Da�e Well
���D ; / '� /!�j / or Bonng Constructed / �j�O �
'ra '�a 'i.i � / C) /
Numencal Street Address or Fre Number and City of Well or Bor�ng Location 1 )
CJ`C' �'� �
� �-��-��� � ��� „���� ;_� �U� Depth Before Sealing � � "ri. Original Depih � �� � ft-
Show exac�location ol well or boring � Sketch map of well or bonng Static Water Level Q�Accura�e
in se tion grid with��X� � location.showing pwperty lines.
��..O�Q N � % roads.and bwldings ❑Approxima�e
�V
1
-- - i i i_ r'fL.f
�� ��� �� �ngle Aquder ❑Mult�aqwfer � 1 fl. below above land surface .
i i i i �
_i_ _�_ _a.- -i_ CASING TYPE
W i i i E *�
� � � � � � IY�V T 7 � . .
-r -i- -r- -I- �
i i � �Steel ❑Plastic ❑Tile ❑Other
mile
__ _ I I I_ � �t)t�
I I I
Screen from to fL Open Hole�rom to iL .
S L, u _ {�� r
�--�mi�e---� - ' " OBSTRUCTION/DEBRIS/FILL
��i,: t_ �y
tn,Obstruction ❑Debns ❑Fdl
PROPERTY OWNER'S NAME /
, , ' t.
r � -' � C_:I`'- � 1 j� . I i Y �`,
Type of debns/obsiruclion .- ����
Maihng Address d drfferen��han property address indica�ed above
Obsiruction/Debris/Fill removed7 �Yes ❑No
- �=:. �/ �� PUMP
I�Wemoved ❑Not Present ❑ Other
CASING
GEOIOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depih Set in oversize hole? Annular space initiaily grouted?
It not known,indicate estimated formaLon log from nearby well or boring. � � ��,+
/ �� ,a/� �,/
}� �,V�\ in.from to ft ❑Yes L�1+lVo ❑Yes ❑No QUnknown
/"a
in.from to it. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to fi. ❑Yes ❑No ❑Yes ❑No ❑Unknown `
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�o Annular Space Exists
❑Annular space grouted with tremie pipe
❑Casing Perforation/Removal
� in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Pertorated ❑Removed
�:;
-��'" Type ot perforator
❑Other
GROUTING MATERIAL
�
+1 r ; 1. ,!I ,�
Grouting material �������- '��' �`-U` � ` � from ' to � � ft. yards �—"' bags ��
from �o ft. yards bags `
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
��� from to fl. yards bags ��
�
�, �:
_. �i�..�_ , �, � � t
trom �o ft. yards bags :
s
�/,. � "�'�� � UNSEALED WELLS AND BORINGS
� '� 4
� = (_� � �-�'` I' l
Other unsealed weli or bonng on property? ❑Yes �No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The informa�ion contained in this report is .��
irue ro the best of my knowledge.
�Y , I I c�, � �� G�
Contractor Business Name License or Registration No.
E;
� �; � ? - 96
-,-�i�— :
Authorized Repres�ntative Signatwe Date
LOCAL COPY H , � �.'^� �,,/ �F K ����
1217 5 3 Name ol Person Sealing Well oi Boring
HE-01434-01 .