HomeMy WebLinkAboutwell info Minnesota Well and Boring 2 8 8 01
wELL oR BORING�oCA7ioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H -,�
�o���Y Name WELL AND BORING SEALING RECORD M���eso�a u��q�e No �
i � � Minnesota Statutes.Chapter 103t or W-series No.
ILeave blank il not known)
�i.
Township Name Township No. Range No. Section No. Fraction(sm. •Ig.) Date Sealed Approximate Date Well
�;��� ' ,,. y ' � �`] S or Boring Construded �
s-:; �n�la�in �� [ �-� 1
s�' Numencal Sireet Address or Fire Number and City of Well or Boring Locahon �
(� �:
�� Depth Before Sealing " � ft. Original Depth �� Fl. „��
��-� Show exact locahon of well or boring Sketch map ot well or bonng Stalic Water Level Accurate �
� '� -fn sec�ion grid with��X��. loca�ion,showing propehy lines.
N roads.and buildings. ❑Approximate
-i- -i- -i- -� !� � � . � �
Single Aquifer ❑Multiaquiter '" � fl below above land surface
i i i i
s-�- _i_ _�_ _i_ _i_ � CASWG TYPE �`
` W i i i i E �' �
t � �
� � � � T ;,. �' ,
�_. _i_ _�_ _r_ _i- �` ,y"� `�
� � i � ,m_�e Steel ❑Plas�ic ❑Tile ❑O�her .k
_i i i i_ � -� �
o- ' i_ _ 1_ _i _ _i �
S Screen from �'O G to � tL Open Hole from to ft
� �
y - 1 mile
� � OBSTRUCTION/DEBRIS/FILL
��� PROPERTY OWNER'S NAME Obs�ruction ❑Debris ❑Fill �
�� �{ ` �
� Atli]I�ttE�' W@LffiOL� �J �'...£,,, �.S v'�ti^ �✓�i s'��C� L c7� �,c��nc. �
Type of debris/obstruction ,�
Mailing Address if different than property address indicated above. -
Obstruction/Debris/Fill removed? Yes ❑No ?
',�� : ..�_., � . : PUMP ,�"�
L; - � . , .. . �
r�
Removed ❑Not Present ❑ Other ,(�
�' CASING �
HARDNESS OF �?
GEOLOGICAL MATERIAL COLOR FORMATION FROM TO
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring. \ �
� �.�f� � � �in.from -LL to � ft. ❑Yes p�No ❑Yes ❑No ❑Unknown ?'
�,� �
t��' in.irom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
°=�:;'
� In.from to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown
�;
��,i:' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
'„�-:� �No Annular Space Exists
. ❑:�nnular space grouted with tremie pipe
<'.
❑Casing Perforation/Removal
� c
� •� in.from to ft ❑Pertorated ❑Removed
'nFi> in.from to fL ❑Perforated ❑Removed
�:;i�: � . . �` .
i r
.� � Type of perforator �
�
�� �
^ _ _ - ❑Other �
�-r; :
�,;. GROUTING MATERIAL
{� `/ Pr '� r.
>�o Grou6ng material 4"`�-�R�{ `"'£'M � from � to �ft. yards �,�bags
g�� from to ry, yards bags '4-_.a�
'�::
"- REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
�
'�-`- irom to ft. yards bags
Fi'`
��`' �L'd11� Z~ 1�1'�'u E31i� �
� 2 1,..8 C��♦ . � from to fl. yards bags
_. ! It�.. 1.,,_,.t,.�.d�e UNSEALED WELLS AND BORINGS
+t Uia �JGLl VELR
�`;' A_.,_ t..L��! _.{n t. �� �iw � Other unsealed well or boring on property? ❑Yes No F,
L�tXld 1#3W i$ �s �vaiL �_
LICENSED OR REGISTERED CONTRACTOR CERTIFICATIdN
��;_:` This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
. . true to ihe best of my knowledge.
� � aa: �.. � . -
``.�' D0�1 SCOC�:0�.8 W��.1 D��.Z� CA.� �17C. 2717�
� �,� '"`=' - Contractor Business�e License or Registration No.
�� � . - �� �. ./� /' � 5"17"g3
� �
��' r�' ,
�;��:;, Aut nzed RepresentatNe Signature Date
l r � �R� i�C1SHL�
LOCAL COPY '„I �n(�O� `
8 8 Name ol Person Sealing Well or Boring
�`���,�"HE-01434-01 �
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