Laserfiche WebLink
;. Minnesota Well and Boring 419� � � <br /> -: WELL OR BORING LOCATION MINNESOTA DEPAR?MENT OF HEALTH Sealing No. H � <br /> �o���Y Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No. <br /> I Minnesota Statutes. Chapter 703/ or W-series No. <br /> �'-7�l��� ILeave Olank if nol knownl <br /> � <br />'� Township Name Township No. Range No. Sectron Na Fraction(sm. �Ig.) Date Sealed Approximate Date Well <br /> ) � ; f .:; '�� or 8oring Constructed � .-� <br /> ��� � �t � ,-! �ia �ia �rn t� � � -. <br /> Numencal Street Address or Fire Number and City of Well or Boring Location / / � <br /> 7 �j[ k � i b�pth Before Sealing ,��� ft Original Depih - �� � it. <br /> �r� -FF�i''L /�!,!��� �.'It t� . <br /> Show exact location of well or boring Sketch map of well or bonng Static Water Level ❑Accurate <br /> in sedion grid with��X��. location,showing property lines. <br /> N r: • + � <br /> roads.and bwldings. �Approximate <br /> _i i i i_ � ��o...__ � �s� <br /> i" _ i_ _i _i � ' <br /> � ` Single Aquifer ❑Multiaquifer �� ft. �� below above land surface <br /> i i i i <br /> -�- --+- -i- -'- CASING TYP <br /> W i i i i E <br /> � i <br /> � � � � <br /> �_ _ ._ .. <br /> -r -�- -r- -r <br /> � � � � mi�e Steel ❑Plastic ❑Tile ❑Other <br /> n � <br /> i _i_ i i � <br /> _i_ i _i_ _- <br /> ... . ��--.- __.-_.-._ ....__... <br /> S � -� � Screen from to fl. Open Hole from to ft. _ <br /> ��`"'1e� �'� � � � OBSTRUCTION/DEBRIS/FILL <br /> �i Obstruction ❑Debris ❑Fill <br /> � PROPERTV OWNER'S NAME <br /> ..'i ( - � .-�_, . � � <br /> ' , = , • -;r � F � �, , �., j Y _ <br /> � Type of debris/obstruction <br /> Malling Address rf ddferent than prq�erty address indicated above- - . <br /> Obstruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> ❑Removed Not Present ❑ Other <br /> CASING <br /> HARDNESS OF � <br /> GEOLOGICAL MA7ERIAL COLOR FORMATION FROM TO <br /> Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> If not known,indica estimated formation log from nearby wel!or boring. <br /> —� / ) <br /> / j� �in.from �.= to _/__L� fL ❑Yes �No ❑Ves ❑No �Unknown ' <br /> ft j . <br /> . � <br /> I in.from to fL ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.(rom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br />� in.from to ft. ❑Perforated ❑Removed <br /> in.trom ro ft. ❑Perforated ❑Removed <br /> R <br /> Type of perforator <br />�; R 2 6 �Q� <br />�e ❑Other <br /> t" <br /> GROUTING MATERIAL <br /> Grouting material f't`�'Yr'l��i'i� trom �„to �ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAIING <br /> from to ft. yards bags <br /> - ��;�c�C.( f.� ; <br /> from to fl yards bags <br /> � � UNSEALED WELLS AND BORINGS <br /> ! r� <br /> � � �/ Other unsealed well or boring on property? ❑Yes No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFI ATION <br /> This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> 1��� ���� c ,j � .�/ r-/ <br /> Contr�usme�s Name LiC'ens��g�i'ffation No. <br /> �'` ,�- �{/r.„ tr „'L .:%i'� � � <br /> Authon. d��Represen��e ign re Date '� <br /> /i <br /> LOCAL COPY �..� !1:. If t; !�.�,yS 7 1 `! ; �;, <br /> 419 5 7 Name f Person�ali lI o1 B ring <br />�� H601434-01 � � � � - <br />