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Home My WebLink Aboutwell info � Minnesota Well and Boring 3 9 8 8 0 y WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �- �o��Y Name WELL AND BORING SEALING RECORD M��esota u��q�e No '' Minnesola Siatutes.Chapter 1031 or W-series No. � �, �-� (Leave blank if noi knowni Township Name � Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Welf � �}` �'} or Boring ConsVuc�ed r::;;{)�'�„r / ✓b h',a�s.r'rgf�c�',a � y� (/ j � � Numerical Sireet Address or Fire Number and City o(Well or Bonng Location i��.. r:�� /�'� �� _ � Depth Before Sealing :� u (t. Original Depth —��,' ft. � - .. i .r�.., � Show exact location of well or bori Skelch map of well or boring Stafic Water Level [�Accurate in section grid with��X��. location.showing property lines, roads.and buildings. ❑Approximate N � �� _i i i i_ L'J .�"`�� -�- -�- -i 7` Single Aquifer ❑Multiaquifer �fl. X below above land surface i i i i _i_ _�_ _i_ _i_ CASING TVPE W i i i i E � i i i � � } � i � _i_ _�_ _r_ _�_ 'f � � � � �amiie Sleel ❑Plastic ❑Tile ❑Other -� _i i i i_ � �� /� i_ _ i_ _i _ _i Screen from ;,�7--�— to ��' tt. Open Hole from to ft. ��S'�e �I OBSTRUCTION/DEBRIS/FILL �Obstruction ❑Debris ❑Fill PROPERTV OWNER'S NAME 1 � ��; .�,�:''_ '�. :r ,, •�,�� , � ��.t..` �{ ��-"-�'dL' Type of debris/obstruction Mailing Address rf differeM th�['eAy address in � ted above. Obstruction/Debris/Fill removed? Yes ❑No PUMP . _ a �Removed ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION � Diameter Depth Set in oversize hole7 Annular space initially grouted7 If not known,indicate estimated formation log from nearby well or boring. �in.from to �— ft. ❑Yes �No ❑Yes ❑No ❑Unknown t, 1. in.from to fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown _�,- {--. in.from to k. ❑Yes ❑No ❑Yes ❑No ❑Unknown - €:'.�- (J r,.' . . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �lo Annular Space Exists ❑Annular space grouted with�remie pipe ❑Casing Perforation/Removal in.from to ft. ❑Periora�ed ❑Removed in.from to fl. ❑Perforated ❑Removed Type of perforator � '1 � ��J3 ❑Other ,� GROUTING MATERIAL Y , r Grouting material � ' ' from to r��_fl. yards f bags from to ft. yards bags REMARKS,SOURCE A,DIFFIC@LTIES IN SEAU � �. 1' ��r-(`UJ from to ft. yards bags L�U V � �� :: t � from to fl. yards bags "�`�� UNSEALED WELLS AND BORINGS � °"� ,��'�,,c '�-,: 'F` - Other unsealed well or boring on property? ❑Yes �lo '�� .� ' - � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION : �;K ��,*��., �''---� � ��w? This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is 2„ ��. ��i �, _ � irue to the bes�of my knowledge. -a .. s ' � ' � . �� ..: '�`,rs�. . _; . N . ,a� ,.�� 4: �� .: '�a �1.'S•'��: �� l/ ..1 (.�.. y„/ J �/ } / �! - - t `r�.'-. �:,<� .. .*�/`�.. ./'! ~ J .1 � p � �s . ' Co ractor Business Name - License or Registration No. � . x_:, .. ._� ,. 2�` �,. `� -�,� .,c-_._? .... -+�....._,✓ ,. - n x� _ . _ j �7 - i ! f v % �" � Authorized Repiesentahve Signature Date � ir,, LGCAL COPY I„I : � - � Name ol Person Sealing Well or Boring HE-01434-01 �� a- . .:..__ ..... ,.; .:.... . . .�,.. . _..� . . _-.,....�. _ . . . � .. � ..' . . . . . . . .: ... ._ .. � ,..„.,,.. . ... � �< _. . . . . � � .',,r_. WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. CountyName WELL RECORD Minnesota Statutes Chapter 1031 5 3 Q 15 6 Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ,,;. �.,.: ..3,- / � ,� ,� 3 ' ` s h..,,.��,. .��, ,. � o h 7 J -r�' .J' Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD � - � . --�� ❑ Cable Tool ❑ Driven ❑ Du r � `� -' f G:i., (.^ i �.;�'�' � !' '� tr ❑ Auger �Rotary ❑ Jett d Show exact location of well in section grid with"X". . Sketch map of well location. ❑ �,, Showing property lines, N roads and buildings. DRILLING FLUID I � � I"'`` . . --r--7- -� -1- - i�`-� .:.<' '_ - i � i i . � ,USE �Domestic 0�Monitoring � Heating/Cooling '-�" --- - �- ❑ Industry/Commercial W � i � � E ❑ Irrigation ❑ Public _1_ _;_ __ __ T r c� �� ❑ Test Well ❑ Dewatering U Remedial � ' i � � � � ��"'"'� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. ' 1'-�- �- — —�' ��._,�,_„�_.,�^—'"' ❑ Steei ❑ Threaded ❑ Welded ,�lastic ❑ �I mile� { �``�� `�� CASING DIAMETER WEIGHT PROPERTY O�ER'S NAME �in.to /� � n. ..� �/ J Ibs./n. � ;n.to .t'vn. , : E. ;_:�.� in.to ft. Ibs./ft. e" i%�n.to��ft. Mailing address if different thanpjp{ierty address in � �ted above. _ in.to ft. Ibs./ft. in.to ft. SCREEN OPEN HOLE � Make ,,� %� C � from tt.to ft. . Type /��L�-- Diam. � SIoUGauze J a Length Set between � (J J ft.and �u ft. FITTINGS: �/`� r-.. HARDNESS OF STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 7 (� tt.�below ❑ above land surface Date measured � -•% � � . -� ..., PUMPING LEVEL(below land surface) /.. ��-�.` : /��fj � _ ( ' J�. -- � �..J/ N�'�v-- �j'L�W� �.� ,J� � U fl. atter ,t hrs.pumping �� t7 g.p.m. � WEIL HEAD COMPLETION i% ��F� ,�'(.� � /_� �f/� �� .Pitless adapter manufacturer �^-�-��-��-- Model -> � ;I ❑ Casing Protection ❑ 12 in.above grade 4 i � � � J ,,.�" � •. �'=ri,-_;�� ..r �r r„_,.� S i!_'� GROUTING WFORMATION - Well grouted? [9�Ves ❑ No Grout Material ,�'Neat cement ❑ Bentonite from_ �to � fL + ❑ yds. 69� bags from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION - , ;;�w. _�%�,r/ type - �� -�� feet /� � direction Well disinfected upon completion? ❑ Yes ❑ No ,{i ��_y/ PUMP ❑ Not installed Date installed 1 ,S�� f x Manufacturer's name r-C.��r"x-z _-��-��„�. .. Model number .� J� a n7 HP �� Volts / � J� F Length of drop pipe ,J' � ft. Capacity � � g.p.m. Pressure Tank Capacity ,1 � �� Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �No WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. �. Use a second sheet,if needed �� " �� ' � �-- C ..1 �.ti ..�� =� -;= �s / ✓ l � S FIEMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name Lic.orReg.No. �.,'� ,. -- ��` � -'` ,� s� f Authorized Representative Signature Date �i ' ' / _. ,� i r- . ��_ E_. �- ��..-s__�_.��,. _ � .d � U Name ol Oriller Date LOCAL G��PY � 3 0 :� � 6 HE-01205-04(Rev.5/92)