HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 4 2 21
County Name
WELL AND BORING SEALING RECORD Menn�e90 a�Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
f����/� �^ (Leave blank i�not known)
C [/
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
�r �srai 117 23 �7 R� i�' ��' / r�/ ,G,
GPS LOCATION—decimal degrees(to four decimal places) 1''� /
- Depth Before Sealing � ( ft. Original Depth ft.
Latitude Longitude
UIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer r1 /�/►�J
-n,�i h WELL/BORING �vleasured ❑Estimated Date Measured K/T� �JI'tl'
32�� �'�'sta� �°��' ' � � ,��p� Water-Supply Well ❑Monit.Well f
Show exact location of well or boring Sketch map of well or t�oring J�Env.Bore Hole �
in section grid with"X:' location,showing prop'rtq.,=' ❑Other � ft. �below ❑above land surface
N lines,roads,and buildi gs.,'
� CASING TYPE(S)
--'---—`-----`-----'—
�Steel ❑Plastic ❑Tile ❑Other
� � � � : � l^_lr�
. � , � � i_,
' ""'""" ""'"-"--"`-- ----- ELLHEAD COMPLE
' W , ' , ` E� .. TION
v W
�; __�____�_____�_ ___�__ � � Outside: ❑Well House ❑At Grade Inside: ❑Basem�2!"'��D :`.
'h Miie �4 �itless Adapter/Unit ❑Buried ❑Well Pit
�', ❑Well Pit ❑Buried JUl 0 5 �011
, S , , _
F-1 Mile—� � (]Other ❑Other_
PROPERTY OtWNER'S NAME/COMPANY NAME CASING(S)
�.L1P� ��OT(I�S Diam te� � Depth I Set in oversize hole? Annu ar space ini i
Property owner's mailing address if different than well location address indicated above i �4
�in.from �/ to__ � ft. ❑Yes �No ❑Yes ❑No L�Unknown
17W 1a�A�$rA �.�n� �� ir2� in.from ro ft. ❑Yes ❑No ❑Yes ❑No L]Unknown
Plymcxrth, "�"T 55447
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
t �•u7
Well owner's mailing address if diNerent ihan property owner's address indicated above Screen frOm_�''�to C J�ft. Open Hole frOm t0 ft.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction
Type of Obstructions(Describe) _
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
Type
�'�``� ;.�.� r' �7
❑Removed �Not Present ❑Other _
� METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe L�Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to fl. ❑Perfora[ed ❑Removed
Type ot Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes No TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
�r t �
Grouting Material�L�( ���i�f from � to �� ft. yards� bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes o 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 knowledge.
Tk�n Staiala �+Tell Drillin�; Co�. Inc. 1�91 _
Licensee Business lyeme License or Registration No.
r
�_ 1 /.'! -'"�i,�F _.f''� / ;� /- 1 �
� - f� �
�rtiGed' presentative Sigifature ' Certilied Rep.No. Date
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.� ��2�1 ✓ ; �.-; �:.,� ���-..�
LOCAL COPY H � Name of Person Sealing Well or Boring '� J
HE-01434-14 ID#53159 Si�sR