HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Weli and Boring H � ��4 5 3
County Name
WELLAND BORING SEALING RECORD Mnnesoa�UniqueWellNo.�
e! Minnesota Statutes,Chapter]037 o�W-series No. p
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Township Name Township No. Range No. Section No. Fraction(sm.-•Ig.) Date Sealed Date Well or Boring Constructed
�Can� 2I� 2� Cll S� SE S� �."�.,. 4 ""� �;j,�'`'� !1 .,�;�r
GPS LOCATION- decimal degrees(to four decimal places) ['� � . ." '`
Depth Betore Seating �l�� ft. Original Depth g.
Latitude Longitude ,, �
IFER(S) STATIC WATER L L '�+'✓= , � � �
Numerical Street Address or Fire Number and Ciry of Well or Boring Location Single Aquifer ❑Multiaquifer ' ' � rvf An
�� ����� �� '��nr A^►..,.r,., WELUBORING �teasured ❑Estimated Date Measured S�_ s _�,t�r ��Y�
4�suRiV Water-Su I Weil
pp y ❑Monit.Well c`,��
Show exact location of well or boring Sketch map of well or boring Env.Bore Hole
in section grid with"X:' loc tion,sh�, gpraperty ❑�her +"� ft. �below ❑above land surface
N ,roads,ar)p3bwi ng�. CASINGTYPE(S)
..!✓f ..sc..
--�----i----�-----�-- �
�Steel ❑Plastic ❑Tile ❑Other
--=-----=-----`-----�-- � WELLHEAD COMPLETION
W : : ; ; ET ' �
_ �_____�____�_____�__ Outside: ❑Well House ❑At Grade Ineide: ❑Basement Offset
'h Miie ❑Pitless Adapter/Unit �uried ❑Well Pit
--:-----r-- ---------=-- 1
❑Weil Pit ❑Buried
, � S � � _ _� ❑
__.....,
,A,.___ � -- ther
�t Miie�.. -� � � Y''� ❑Other
� a �> ,(;:_s►..,,
P�R+OPERTY OW�+N�ER'�S NAME/COMPANY NAME CASING(S)
1+� �.�G�� Diameter � Depth � Set in oversize hole? Annular space initially grouted?
Property ow�er's mailing address if diHerent Ihan well location address indicated above I��, �
�in.irom�_ to�_ft. ❑Yes No ❑Yes ❑No ❑Unknown
r���,.�����+� ���T� g in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
1'.V�21UZ A7R��,j C�:� ���.7�
in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
t f
Well owner's mailing address if different ihan property owner's address indicated above SCreen ffom�_to��ft. Open Hole from to ft.
OBSTRUCTIONS
�ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions{Describe)�it)`r�J�� f'"„{f"Y � 1./�r
GEOLOGICAL MATERIAL COLOR HARONESS OR FROM TO Obstructions removed? [�es ❑No Describe
FORMATION
If not known,indicate estimated formation log from nearby well or boring. PUMP
�iL �,+ [�t TYPe
❑Removed �lot Present ❑Other
M�OD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to R. ❑Perforated ❑Removed
Type of Perforator
VARIANCE . .
Was a variance granted from the MDH for this weli? �Yes o TN#
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonke=SO lbs.)
� �g r +�
Grouting Material���i��� from � to T�� ft. yards '�*�" bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORWGS
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 ro the best of my knowledge.
I1o�t Stt�fll� tdeil�ri3lit� �,. �I.t�. llag�.
Licensee Business Na�ne ,, � r- License or Registration No.
,.� .`'` � j''
P ( ."
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C, �iezl R�irt2�$�gnature Certilied Rep.No. Date
" 329453 J�' �''°�
LOCAL COPY Name o/Person Sealing Well or Boring
HE-01434-14 IC#140-0423 5/13R