HomeMy WebLinkAboutwell info�• Minnesota Well and Bormg
.',c�r; MINNESOTA DEPARTMENT OF HEALTH Sealin No. 3?0 6 7 14
Y� WELL OR BORING LOCATION 9 H �;�
� co���v Name WELL AND BORING SEALING RECORD Mi��esota u�iq�e rvo. �
r�` Minnesota Statutes.Chapter 1031 or W-series No.
. � �Leave biank�f not know�i
�� Date Sealed A roximate Date Well �
�A� Township Name Township No. Range No. Section No. FracUon�sm. �Ig.� PP
,���� or Boring Cons�ructed � � �
�.,� �.� j 'ia �la �ra � —' '" .-- ~r' �
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�. �� Numerical Street Address or Fire Number and City of Well or 8oring LocaGon � � ' ".��`
t y \
.�r �.,. 7 r Depth Before Seating �� / „ ft. Original Depth -�i. fL �
�- � � �� -_ -' :°�
�-. Show exaci location of well or boring - � ketch map ot well or boring Static Water Level �Accurate ��
�,i,`; in section grid with��X��. V bca6on,showing property Imes. ��
`�> roads.and buildings. ❑Approximate
'E N
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'_ _ '_ _' _ _' ))) ,y
��� -� � � � � �— ingle Aquifer ❑Multiaquifer �ft. --Yl� below above land surface �
i i i i �
��_ _i_ _�_ _i_ _i_ _, CASING TYPE ;,�
W i i i i E
� � '�
� � � � �i
_�_ _y_ _r_ _�_ '�.
� i i i i • '� � teel ❑Plastic ❑Tile ❑Other �
:t mile �
�,:. _�_ _!_ _� _ _�_
�4 � � I i �
r'
�,: � � , Screen from to ft. Open Hole from �o ft
' �--l miie—►I �. j�,'�I� OBSTRUCTION/DEBRIS/FILL
x ��Q�
��e� PROPERTY OWNER'S NAME ��'�1�'•�°'� �Debris ❑Fill g
2 w
a
���. � r� ��.� " � �' Typeofdebris/obstrucGon � ��-� �� �,� �� �� i : � i; ��` ���.� � �
�*'� Mailing Address if different ihan propeAy address mdicated above. � y+
,c'- Obstruction/Debris/Fill removed? Ves ❑No �„�
"�`�.. ,�"`j�l WL,Q. PUMP
�-��:. . � ��
��
.,�� ❑Removed ot Present ❑ Other
CASING �
HARDNESS OF
t GEOLOGICAL MATEHIAL COLOR FORMATION FROM TO
.�'�*..'„ Diameter Depth Set in oversrze hole? Annular space initially grouted?
a�1'a� If nol known,indicate estimated formation log from nearby well or bormg. '�
� S
�_in.from �,.' to �� ft. ❑Yes �lo ❑Yes ❑No �Unknown ��.
in.(rom to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown _,�
"'^ �
� In.irom to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown '�
T� �
�. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND 80RE HOLE:
a:
�,.. �No Annular Space Exists
�-. Annular space grouted with iremie pipe
�<'„ ❑Casing Perforation/Removal ��
i "
�� in.from to ft. ❑Perforated ❑Removed .�
� '�
F.„
�: i.'.
in.from to ft. ❑Perforated ❑Removed .�,�:
� �
� Type of perforator i:;.
� `�
�� %��
' ❑Other ��
�*'� GROUTING MATERIAL
�
� ,
+ ��
T ;�
,� Grouting material i��.. ` j„��� I/� .�_1'�' from �.,�to �_Jt. yards �bags
� � �
�� �
�� from to ft. yards bags
�� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
irom to ft. yards bags �
' +' �" _.
< �,���� �� i . �,��
) - . '��
r� -
from to fl. yards bags
`�,� �.t�.,y�..�g,��} � , ��l.. i,y� �� , `.. �� UNSEALED WELIS AND BORINGS ';:
� IS
��,� � � Other unsealed welt or boring on property? ❑Yes , o
t ; �� � j
/ �,,t J 1 �s��„� � y f� i �, .. IICENSED OR REGISTERED CONTRACTOR CERTIFICATION
��� � This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is ��
/ �� � �,. ��'l r � � irue to the best of my knowledge. �
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i f � � �
1��� v i ! � �' �
� �� Contractor Business Name License�Registration No. �
� � a 1 � '(
�, - _ r9 `� `,,.�. _ .:-r
,�:��,�,�,,�_ ,�
�`� Authorized Rg�resentative Signature "�� Date
��' � . , , , :../
� LOCAL COPY �„� � ��. �- t'' � i . - vt ` ! �
�: Name ol Person Sealing Well or Boiing
��, HE-07434-01 .