HomeMy WebLinkAboutwell info WELL OR BORING LOCA71oN MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �2 7 3 3�
M WELL AND BORING SEALING RECORD Sealing No.
Counry ame Minnesota Unique Well No.
-% �;,/% Minnesota Statutes,Chapter 10.?I or W-series No.
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Tqvr�ship Name wnship No. Range No. Section No. F -i ly� Date Sealed Date Well or Boring Constructed
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GPS Latitude degrees minutes seconds ,^} � � �
IOCATION: Depth Before Sealing �� � � tt. Original Depth R.
Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Loca�ion �`]Single Aquifer ❑MulUaquifer
,-- ;J� � WELLBORING �'Measured ❑Estimated
f� r � �.. Water Supply Well ❑Monit.Well
Show exac location of w I r tch map of we or boring
in section gnd with"X" zS ocation,showing property ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
; � � � �
,. --r- -T- -�-- -�-- ---_ . .
. . . ...._ ... - �
� �]steel ❑Plastic ❑Tiie ❑Other
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W -�- '-- -;-- --i-- E ' �r„�g.q..�--�^ WELLHEAD COMPLETION
� � � � � � utside ❑Well House Inside: ❑Basement Offset
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—�- -;-- -r- --�-- ' .. �
_.�! `C�/_-'-�-
�^� �. � � �Pitless AdapteAUnit ❑Well Pit
--`- -i-- -i-- --�-- � ! J,
`-"�� r' ❑Well Pit ❑Buried
S ��-�"""—�' ❑Buried
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PROPF�RT�OWNER'S N�jME/COMPANY NAME s' ', CASING(S)
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�{`:- Diameter DepV� Set in oversize hole? Annular space initially grouted?
Pia ownePs maif� �address 1F�' tio ad indicat
� I�.from��*'to�ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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i ;_j : � � �' �` � �1 r� ❑ ❑ ❑ ❑Unknown
� � � l� - ���"��� / �=�-- in.from to ft. ❑Yes No Yes No
S.�' -.
�� i� .�j�� . /�. . � � t� ��� '`4, in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
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WELL OWNER'S NAMEICOMPANY NAME SCREEWOPEN HOLE
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Well owner's mailing address it different than property owners address indicated above Screen from�t0��� Open Hole from t0 ft.
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OBSTRUCTIONS
❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y2S ❑ NO DBSCfib@
FORMATION
If not known,indicate estlmated formatlon log from nearby well or boring PUMP �
Type ��y,�b'/'
p,Removed ❑ Not Present ❑Other
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 Perloration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Matenal f �, , �!'.� ` ' to �, ft. yards f� bags
from to ft. yards bags
from to tt. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION "
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 kno�yvledge.
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CaiVactor$us s . �nae or ist bon No.
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Aut ni . nafure�'- . -• � Date
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H 22733� �
LOCALCOPY � �
Name ol Perso��'' 'g e or ng