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