HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring F„� ��['��(1�
Counry Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. �r �"�
Minnesota Statutes,Cha ter 103I or W-series No.
P i�ea�e ma�k��o�k�ow��
' Township a Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
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GPS Latitude degrees minutes_______ seconds Depth Betore Sealing � �� ft. Original Depth ft.
LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL
,' Numerical Street Address or Fire Number and City of ell or Boring Location ,Single Aquifer ❑Multiaquifei �/� (�/'�f/
� Measured Estimated Date Measured M� I?1'r
�'j rb/�D WELL/BORING � ❑ 7'�
Water-Supply Well ❑Monit.Well � t
Show exact location of well or boring Sketch map of well or boring --�Env.Bore Hole
in section grid with"X." location,showing property � ❑Other �ft. �below ❑above land surface
N ines,r ds,and}�iings. CASING TYPE(S)
f ' , 1
� ; ; ; ; -y."e5t l 1�.
--�-----�--- --�----•--
` scee� []P�astic ❑ri�e []omer
; ; ; ; `--__...._,,
-- --------- -- ------- � WELLHEAD COMPLETION
: W E
;__ _ _ T �� Outside: ❑Well House �_;At Grade Inside: �Basement Offset '
� �
, , , 'h Miie - ` itless A p r/Unrt �_.I Buried ,�Well Pit
, , , , � ���—�- �]P� da te �
--�-----�--- ---%----+-- •_„�� �J Buried '
� � S � �
��)"` ❑Well Pit
�1 Mile
� ❑Other ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Diastetgr� ' Depth /�' � Set in oversize hole? Annular space initially grouted?
Prope n ma i A� different Ihan well location address indicated above '� in.from �✓ to�ft. ❑Yes �f No ❑Yes ❑No ❑Unknown
�iTJL n�� nCilt R� in.fram to ft. �J Yes �.-_]No ❑Yes ❑No ❑Unknown
deephaven, M� �5331
in.from to ft. ❑Yes []No ❑Yes ❑No ]Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if different than property owner's address indicated above SCfeen from CJ ' to j �� ,ft. Open Hole from to ____ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
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Type of Obstructions(Describe).�f�,/�.�'�� ��/�'� ¢' �J'�r
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obsiructions removed? �Yes ❑No Describe
FOHMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
. a TYPe
�c
U Removed �ot 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 Perforation/Removal
in.from to ft. ❑Perforated �❑Removed s
in.from_ b ft. ❑Perforated [_)Removed
Type of Perforator
❑Other
GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag of bentonite=50 Ibs.)
Grouting Material ���1`��N�'f o_�_ to_�s.lZ ft. yards �+O ba s
9
from to ft. yards bags
- from to ft. yards bags
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OTHER WELLS AND BORINGS
qEMARKS,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 knowledge.
Dan Stoclola WeTI Drillin� Co., Inc. 169I
Licensee Business Name � --- License or Registration No.
_ e�,�� �-- /1- �U
C Yf t'e 7i a�v ignatur�� Certified Rep.No. Date
H `'� ,_._ '.,,�;�Y=.,a.:x�,+��
LOCA!CCPY 2 9 O O a 2 Name of Person Sealing Well or Boring �
HE-0143412 IC#140-0423 siosR
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