HomeMy WebLinkAboutwell info .. �;',.. ` ' �,: ...�.; �,?��s:�'
.
... .. . . . _ -. � ,.
. < <.: ..... .. .,...,. .. . . . _:. � . ,..�. .. . :.-... > .,._ ._- :. ,... ,. . .,.._,. .�,�.:. . .,... .�..z._ . �
MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring r �C� ,f! ��� �
.LL OR BORING LOCATtON S881ing NO. i H— a��, �
unty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. —
Henr�epi n Minnesola Sfatutes.Chapter 1031 or W-series No. �– �
(L�a:s deN�X rwt known)
a Township No. Range No Section No. Fracnon�sm.-s Ig.) Date Sealed Date Well or Borinq Constructetl
'� �r� z3 i� 4�-a�z� r u �
Numencal Sheet Adtlress or Fire Number and Ciry ol Well or Bonn�yoc`at��ory� � �
3452 f j 2 V 4��.�J P 9 � ' — 9 P �� --
Li�lA�8t0� Ave• � y�p�a De th Before Seal�n fl Ori inal De th fl '
. � Show ezact location of well or bonng 55391 Sketch map of well or bonng A UIPER(S) STATIC WATER LEVEL
in section gnd wrth'X'. I�cation, showing property Single Aqwter � Mulimquder
, �ines,roads,and buildings. . - � , . , ,
; N ry,— WELUBORING �Measured ❑ Estimated.,.�'. �• ���� �" � "
� � [�Water Supply Well ❑Monit.Well /
� n Env.Bore Hole
❑ ❑Olher _ _�R. �i below ❑ above land surlace
W --�- -i-- -i-- --i— E CASING TYPE(S)
�' --�- --�- -�-- --�-- � . ., �teel ❑ Plastic �Tile � Other
� I I I }lmile � .
—�- -j-- -�-- --�— � CASING�S)
' ' Diameter Depth � Set in overs¢e hole9 Annular space initially grouted7
�(.—i mxe� .. =-�'i;_-r .�J?..y� � n.from�_ to� ft. ❑ Ves �No ❑ Yes ❑No ❑ Unknown
I
pWIA q�y��rg Clpq� asa.�������--�-�9�Z^A (1�,T/ �n.trom ro k. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown
�t` I -s r
Property owner's maiGrg address if diHerem than well location address intlicated above. in.from to ft. ❑ Ves ❑No ❑ Yes ❑No ❑Unknown
SCREEWOPEN HOLE
r
Screen from�.L to�,it. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME (�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well ownefs mailinp address i�diHerent t�an property owner's atldress indiceted above. Type O(Obsiructions(DesCribe)��V N r rL �r��� �`" / �U/� �1 �
. Obstructions removed? �'es ❑ No Describe
PUMP
Tvve .�U�.; f-'t�(j'�1'
GEOlOO1CAL MATERIAL COLOR HARDNESS OF FROM TO +a Removed ❑ Not Piesent ❑ Other
FORMATION
N rat known,indicete estimated fotmatbn log irom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� : f�Jo Annular Space 6cists
`�-� �"�0' ❑Annular space grouted with tremie pipe
� ❑Casing Perforation/Removal
in.trom to R. ❑ PeAorated ❑ Rertroved
in.from to n. ❑ PeAorated ❑ Removed
Type of perforator
❑ othe�
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
A' /'�'' rl�t �,�} / 1
Grouting Material !"���� (t���`iFortS "" to�ft. yards ` O bags
fran to R. yards bags
from to R. yards begs
from to__ fl. yards begs
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property7 ❑Yes o How many?
LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoA is
true to the best of my knowledge.
Don Stod4la Well ilriiling Ca. , Inc. 27172
Contractor Business Name � License w Registration f:o.
,_ �"'?/ __ s r-� � ,.� t �� � �
•,,'� � /' -'�-`'' 7 r i� �._.,d � t '�✓
�nta Signatu Dete
�` - r..'��... ...... ;�Lf �,� , Ja,_„J.i-`l�w.
LOCAL CC?Y H 18 4 7 3 0 Name o�Person Saeling Well a Bonng