HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I �C��Q�
Counry Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. v "
Minnesota Statutes,Cha ter 103I or W-series No.
P (Leave blank i(no�knownJ
Township Na e Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
Q '' l� tJU�,/� ��'7
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GPS Latitude_ degrees minutes._ seconds Depth Before Sealing ��!� ft. Original Depth_ ft.
LOCATION: Longitude degrees_ minutes_ _ seconds �UIFER(S) STATIC WATER LEVEL
Nuqm.e�r�ical Street Add�re1s.s,.or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ]� ...,�� A f�
&JQ� N• �nJV� ��• ��� 55391 �✓ LUBORING �'J'Measured ❑Estimated DateMeasured - ��
�Water-Supply Well ❑MoniL Well �}� `L
Show exact location of well or boring Skeich map of weil or boring �J Env.Bore Hole ❑Other �`-� ft.1f�.�,below ❑above land surface
in section grid with"X" location,showing property � — �
lines,roa s,and bui ngs.
N � CASING TYPE(S) '
f �,�
"_'_"_ '_i___ ___`'_ ___'__
- �Steel r,Plastic ��;�Tile ❑Other ___,.__ _ ___
� --�'--"'-----'`" "'1-' WELLHEAD COMPLETION �
; W ; : ; : ET -
r • h Miie Outside: ��P ell House !L_J At Grade Inside: �Basement Offset
�—"`""�"'r, ,�, tless Adapter/Unit Buried !�Well Pit
-- - -- 1 �''
]Buried
S ❑Weli Pit
❑Other
f--1 Mile� ❑Othef
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
� Diaiaet�y � Dept^ f Set in overs�iz/e hole? Annular space initially grouted?
Properry owne mailing address if different than well location address indicated above � � to ����it ❑Yes '�lo �_ .Yes '�No ❑Unknown
in.from
1I402 Co�mty Road 3 in.from to ft. ��Yes ❑No [�Yes ❑No ❑Unknown
Hopkins, I�d 55343
in.from __ to ft ❑Yes ❑No �=�Yes �]No �,�Unknown
'� WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
��/� t
� Wel1 owner's mailing address if different than property owrer's address indicatetl above Screen from__. ����to•�t. Open Hole from to ft.
OBSTRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction� . �a
.� ' f� �/ � � ;
TypeofObstructions(Describe) � /�/V ..-�� !'_�6�'__4' [.[/�7��
�
4 GEOLOGICAL MATERIAL COLOR HFORMATIONR FROM TO Obstructions removed? �Yes ; '��No Describe__ _
PUMP /1
If not known,indicate estimated formation log from nearby well or boring. Type ���` �,/��{�
' . � ' i
� 1`-� v � 7��Removed ❑Not Present ']Other_ �
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,QR CASING AND BORE HOLE:
No Annular Space Ezists ❑Annular Space Grouted wi[h Tremie Pipe ❑Casing Perforation/Removal
in.from to _ ft. ❑Perforated ❑Removed
_._._ in.from .__to__ _ ft. ❑Perforated ❑Removed
i
Type of Perforator__ _ __ __ _ ____
❑Other _______ __ .
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
n r �
- Grouting Material���T C'����'U'irom_ �`''�" to �_ZCsft. yards < • bags
from_ _ ro 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? r'��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 Staiol.a Well Dcilling Co,, I�. 1691
Contractor Busin s Name � � License or Regrsfration No.
_ " .�'- 1�r. c7
Certifi epresentative Signature� - Certilied Rep.No. Date
H �+�.► ���''�''Q-*�°�'`--j
LOCAL COPY 2 616 8 2 *l
Name of Person Sealing Well or Boring
HE-01434-09 IC#140-0423 ..` s/oeR