HomeMy WebLinkAboutwell info Minnesota Well and Boring 4 4 8 6 �
�'� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealmg No. H
�o���Y Name WELL AND BORING SEALING RECORD M���esota un�Q�e No.
p� _ �� Minnesota Statutes.Chapter 1031 or W-series No.
�qp�1p��„ fLeave blank il not knownl
.. JYf
Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well
� ��� � �� �n��t '/4 � n or Boring Cons�ructed
D�lh/ 1 � �'i
_ Numencal Sireet Address or Fire Number and City of Well or Boring Location �ry � �
35� ": .g�{)j'� �,j�Q ir[i�� 55391 Depih Before Sealing �G�r,� fl Original Depth 1 �� ft
Show ezact location of well or boring Sketch map of well or bori g Static Wa�er Level ccurate
in sedion grid with��X��. 7 s location.Sabwing property lin s.
� � �v roads.and buildin s. ❑Approxima�e
N .
� � � i
� I
_i_ ___ 'i_ __
ingle Aquifer ❑Multiaquifer � ft. � below above land surtace
i i i i
_i_ -�- -i_ -i- CASING TYPE
W i i i i E
� � � �
-i- -�- -r- -r -
i i i i — teel ❑Plastic ❑Tile ❑Other
mile
I 1 I I ' /
I I I I } �(�, � ��)
S � Screen from�--�— to �— fl. Open Hole from to ft.
�--i mi�e—� ,.,,.. /. . . � ,� ���� l<l. OBSTRUCTION/DEBRIS/FILL
� �ObsVuction ❑Debris ❑Fill
PROPERTY OWNER'S NAME
7.�1� �Sc:Kirs�e �rli b73 i�c,P �/�f g �UIY►(3
- Type ot debris/obstruction
Mailing Address d different than propeny address indicated above.
Obstruction/Debris/Fill removed? �es ❑No
PUMP
Removed ❑Not Present ❑ Other �t;��- �luf�,(�
CASING
GEOLOGICAL MATERIAI COLOR HARDNESS OF FROM TO
FORMATION "
Diameter Depth � Set in oversize hole? Annular space initially grouted?
- If not known,indicate estimated formation log irom nearby well or boring. � �
a��t O �� �in.from �to _!— ft. ❑Yes �iJo ❑Yes ❑No ❑Unknown .
11L 1
in.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown
in.from to fL ❑Ves ❑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 iremie pipe
❑Casing PerforatioNRemoval
- in.from �o fL . ❑Perforated ❑Removed
in.from to fL ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
,�! �+ r /�
Grouting material ti�-�� C—�r���rom �_to /Z/) ft. yards �t„�bags
from to fl. yards bags .
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
c�c�a 4„ �u �.zo• a��
lo �w� ��� from to ft yards bags
�x�
le��, �t�t� UNSEALED WELLS AND BORINGS
L��i
� �wy�r' r�o � ��* ��� � Other unsealed weli or boring on property? ❑Yes No
KfIN fj e..
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.
F�ii StbC�.0�8 � �l�fllg �i0.� �$C. Zn�
Contractor Business Name License or Registration No.
y;,a��,�'�„_� - ` - ��—��
Author¢ed Representafive Signalure �e
�OCAL COPY H 4 4 8 6 fi `'�"' �'`°�
Name ol Person Sealing Well or Boring
HE-01434-01