HomeMy WebLinkAboutwell info Minnesota Well and Boring �
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 2 9114 i
�����Y Name WELL AND BORING SEALING RECORD M�nneso�a���q�No �
1 Minnesota Statutes.Chapter 103/ or W-series No.
r—��'y��rl� fLeave blank il not knownl $�,
;ti
Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well ��
� or Boring Constructed � � ���"
v o,.�a ',a '�a ',4 �' ll' / �1 �� /�/y �
Numerical Street Address or Fire Number and City o(Well or Boring Location ��.�
r ti F- .,�j �..
�� (,' � �� , F�� l �� ���G Depth Before Sealing it. Original Depih � � iL �
i\
a
Show exact tocation of well or boring Sketch map of well or boring Static Water Level �Accurate �._."z�.
in section grid with��X��. ,bcation,showing propehy lines. ��
N roads.and buildings. ❑Approwmate '�`�
_� � � �_ Lo„�q L ,,ek;, � 7 �
� ��' '�� �� �,Single Aquifer ❑Multiaquifer -� ft. � below above land surtace ��«
� � � � lJ:.'�
_i_ _�_ _i_ _i_ � CASING TYPE �`�
W i i i i E � .,
�
� � � � � i
-i- -�- -r- -i- � �
� � � � � �Steel ❑Plastic ❑Tile ❑Other r��
h mile _�
_i i i i_ � � �
i i i i ��
S . _ - Screen from to ft. Open Hole from to ft. �
�-7 mi�e--►I ,� I OBSTRUCTION/DEBRIS/PILL
PROPERTY OWNER'S NAME �Obstruciion ❑Debris ❑Fill �
{ %
' ! �1 • r � •��°- � ... ,,,.,. �C�c, t�:�, � !�i l, ' t •�
Type of debris/obstruction -� '� � �
Mailing Address i(differcnt ihan property address indicated above. �
Obsiruction/Debris/Fill removed? Yes ❑No
PUMP �
_ {-i
� •, �.�- ,.. ;i
� ❑Removed ,�Not Present ❑ Other �
� �
CASING �
''9
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION "�
Diameter Depth Set in oversize hole? Annular space initially grouted9 -�
It�not known,indicate estimated formation log from nearby well or boring. �
.A � � 'a in.from �'� to �7 fL ❑Yes �No ❑Yes �No ❑Unknown ����:';a
�\/
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ,�j
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
;*
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ��
�No Annular Space Exisis
❑Annular space grouted with tremie pipe
�.--�' _
. ❑Casing Perforation/Removal
Cii= F,'l
� � � � in.from to ft. ❑Perforated ❑Removed
in.from �o ft. ❑Perforated ❑Removed
Type of perforator
7�
❑Other �
GROUTING MATERIAL
Grouting material � "c-y-����- 1 from � to � ft. yards �bags
hom to ry, yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags �
�, 1�� �. \\ � C'�r `�1� h
-'� from to ft. yards bags
/
UNSEALED WELLS AND BORINGS
_ O[her unsealed well or boring on property? ❑Yes No �
i
� ��"� � LICENSED OR REGISTERED.CONTRACTOR CERTIFICATION
� � _ �..� : This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in�his report is -
#-����� . ��� �. Vue to the best ot my knowledge.
�`';�„� ., x �R„}t ,��L t_� � ( � f� �"!
�'; . � 5„-r �' ���;� Contractor Business Name License or Reg tration No.
.� , ':�` � � � LP-=i_ / � i�, f 5
Authorized Fj�presentative Signature a(e
LOCAL COPY �"� Z�1�� , :���; �-,�_.., i. '� f , f } : � �~y
Name ol Person Sealing Well or Boring
HE-01434-01 �
�