The URL can be used to link to this page

Home My WebLink Aboutwell info i, , _ _ :. _ � � ' MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��'7��(� � WELL OR BORING LOCATION SBflllfl9 NO. II H ( �) Counry Name — WELL AND BORING SEALING RECORD Minnesota Unique Well No. r y{�y Mmnesota Staiutes,Chapter 1031 or W-series No. I I ��il Li� �� .. 0.�ew tleNc M iwl known) L_ _f � Township Name Township No. Range No Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Bonng Consiructetl ttro�o I I7 23 3 7 4��fl9 G> Numencal Slreel Adtlress o�Flre Number and Ciry o�Well or Bonng Location � � 34�9 Lyric �� ' ��0 5�391 Depth Before Seahng�_R Original Depth h Show ezact locahon ot N•ell oi boring Sketch map of wetl or boring ApUIFER(S) STATIC WATER LEVEL in section grid wrth"X". , locauon, showing property Single Aqwfer ❑ Multiaqwfer lines,roads,and buildings. N WELUBORING Measured ❑ Estimated Water Supply Well ❑Monit.Well r ❑ Env.Bore Hole ❑Other _ _ � tt. � below ❑ above land suriace W —�- - -- - -- --i— E CASING TYPE(S) � � � , � � � � � ''r- � -;-- --,— --�-- Steel � Plasfic �Tile � Other }lmile ' —�- -�-- -�-- --i-- � CASING�Sj Diameter Depth j Set in overs�ze hoie7 Annular space initially grouted7 s �! 1� � �—i mna� in from � to n ❑ ves No ❑ ves �No ❑ unknown PROPERTY OWNER'S NAME in.from � to ft ❑ Ves ❑No ❑ Yes ❑No ❑ Unknown Pro wn s i � i erem th a� �res � bove. in.6om to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown ��C �� SL� Q� SCREEWOPENHOLE f 3 A R /,/,rw�r��/'�� ryr�� }�y� Screen from C�to��tt. Open Hole from to ft. V J7 OBSTRUCTIONS � WELL OWNER'S NAME �Rods/Diop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction �/�/,��/� /�e y.� /� Well owner's mailing address if diHerent Man propeAy owner's address indicated above. Type ot ObstruCtions(Describe) .j/� r"�.�/[- /'�: !�"� ��///J�"� Obstructions removed? Yes ❑ No Describe ..,,�. PUMP /'� TYpe ..�C.}C3 {�� GEOLO(i1CAL MATERIAL COLOR MARDNESS OF FROM TO Removed ❑ Not Present ❑ Other � FORMATION fl not known,intlicate estimated�orma�bn log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: � �r�� lo Annular Space Exists � � ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal � in.from to R. ❑ PeAoreted ❑ Removed in.trom �o n, ❑ PeAorated ❑ Removed Type of peAorator ❑ Omei GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) tr Grouting Material � ` f �m � to Sl� R. yards _� bags �� @ i� from to ft. yards bags � trom to n. yards begs ' - from to__ R. yards begs REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHEFi WELLS AND BORINGS '� Other unsealed and unused well or boring on property? ❑Yes o How many? :i i, LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Hules,Chapter 1725. The information contained in this report is � true to the best of my knowledge. C�g$Bd.�A��'�—��r�j�V�"�orReg�__�� ,.a :^ '.e�'.r ./'/ !.,-a'�� i� ��"''£1""VU onz Representative S�gneturs' Dafe 3f� �ntonson �p(��'��„"� � ��w A Name ol Person Sealing Wel1 oi Bonng .. . . H fc�,