HomeMy WebLinkAboutWell info WELL OR BORING LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring j ������ �
WELL AND BORING SEALING RECORD sea���9 No. i H _
co�nry Name Minnesota Unique Weli No. I --
r� v. p �y� Minnesota Statutes.Chapter 1031 or W-series No. II �
.•�y�.i y�y�rJ �S �Leeve tlank M iw�keawn) L_
Township Name ' Township No. Range No SecLon No. Fracuon(sm.-►Ig.) Date Sealed Date Well or Bonng Constructed
f?rona 1 1� � �4�.f �-1'd'WUV� ?6!�� �..✓
Numerical S(reet Adtlress or Fire Number and Cay of Well oi Bonng�ocalion 1 /.+� J
� ���{.i �•i �f"S_�[� !�r� �[��']�,1 Depth Before Sealing ��`�' _n Onginal Depth �`^G� tt
Show exact locatwn of N•ell or bonng Sketch map ol well or bonng AOUIFER(S) STATIC WATER LEVEL
in sec6on grid wrth"X". location. showing property � Single Aywter ❑ MulUaqwler
lines,roads,and buildings. �
�� N WELUBORING �f�Aeasured ❑ Est�mated
, .....__..�_--._�_. ..
; , � � � � ( ater Suppiy Well ❑Monit Well r
_- - - -_ - _ , � ]�EVnv Bore Hole ❑Other _ __��._ft �below ❑ above land surface
W --i-- E ' ._...,,,,,..,,,_,.,_,,,,__. CASINGTYPE(S)
� � � � t
-;-- -;-- -;-- -�- � [�6teel � Plastic �Tile � Other
,\
� � � � ylmile „�v CASING(S)
-�-- -�-- -1-- --�- I
� Diameter Depth r Set in oversize hole� Annular space initially grouted?
S � /�
�r mrie� � ,V � ._�_ in.irom�S.L to��fl. ❑ Yes �No ❑ �es ❑ No ❑ Unknown
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PROPERTV OWNER'S NAME in.trom to R. ❑ Yes ❑ No ❑ �es ❑ No ❑ Unknown
t � :-f:
P�operty owner's mailing addr ss d Alflerent ihan well locat�on address indicated above. m.from to R. ❑ Yes ❑ No ❑ �es ❑No ❑ Unknown
��-#)�t F I e�r i d a 1'!0� SCREEWOPEN HOLE
C,�'����� ���'w 'rj�}�}2� Screen from_��to�'ft. Open Hole from to 8.
OBSTRUCTIONS
WELL OWNER'S NAME r-,,`,�;r' 1 '� �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obsiruction
.. i�. ���� � �. �.....
� /E,�- � f
Well owner's mailing adCress if tliHeient than propeAy owner's atldress indicat above. Type of Obstructions(Describe) +���Jr t"� �' -'-��"� �� `� �-� --
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� ��:7 1'•� . , � !:_' J ,
� . Obstructions removed? �es ❑ No Describe
/,,.1 / ��4 ` . ��` PUMP
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� � �l.,i {�l(� � � � , . �.
4 T
_..� `���� TYPe f�--�^�t �a .�i
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
: ,� �o Annular Space Exists
� -�-� ` , ❑Annular space grouted with tremie pipe
r ❑Casing Perforation/Removal
in.from to ft. ❑ FeAorated ❑ Removed
in.irom ro R. ❑ PeAorated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
.r f�� �� ,�
r'A r`"' � t,
Grouting Material �f�_ , ��_ odAr`� � to�'t� fl. yards � bags
from to R. yards bags
irom to ft. yards begs
from to__ R. yards bags
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑Yes o How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or bonng was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is
true to the best of my knowledge.
�G€I it[3Cl{�Ic� 4-7L�i i4C"! t � ?1'�:" Crl. ' • �'�� ��
Contractor Business Name -� ��—SLicense or Regishetlon I'ro.
r�:� �' �f.�'�_ �.:� :, A;
qY�z�Bd presentative Signatuie i Date
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��., . _._.L .,*:. +„_
������ Name ol Person Sealing Well or Bonng
LOCALCOPY H