HomeMy WebLinkAboutwell info Minnesota Well and Boring
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
County Name WELL AND BORING SEALING RECORD^^��^eso�a u��q�e No.
Mmnesota Statutes.Chapter 103/ or W-series No
� ILeave blank i1 not knownl
Township Name Township No Range No Section No Fraclion�sm. �Ig� Date Sealed Approximate Date Well
`� �� or Bonng Consiructed
Orano lI? 2 ',° .�
Numencal Slreet Address or Rre Number and CAy of Well or Bor�nq Localion �.�,+ i �
3350 2d �hore l�i Depth Before Sealmg �� �� ft Onginal Depih ��� ft
Show exact locatan of well or bonnq Sketch map of well or bonng Static Water Level Accurale
in 5ection gnd wAh��X��. loca�ion.showing propeny hnes. , �
roads.and bwldings ❑Approwmale �J����
N � (�
i R (��
-- -�- --- -- `4., �Smgle Aquder q
.______,� ❑Multia wfer �fl. " below above land suAace
_�_ _�_ _i_ _i_ � �� _. CASING TVPE
W i i i i T +
-i- -�- -f- ET F
� i i '� ' �"'��"' � �Steel ❑PlasOc ❑Tile ❑Other
_�_ ___ _L_ /� � /
� Screen from=���— to / "' ft. Open Hole Irom to ft.
�— �S���� �J - ,_ � ';� 08STRUCTIONlDEBRIS/FILL
Id,ObsirucUon ❑Debris ❑Fill
PROPEHTV OWNER'S NAME / )
'�eit Co Type ol debns/obstruction �N�"�� ��f'�� ¢ ����i"
Madmg Address d ddterenl Ihan prope�y address indicated above.
ObsirucUon/Debns/Ftll removed7 ❑Ves ❑No
I4000 Veit Pl�ce PUMP
Roge=s, �`41 5 5 374
emoved ❑Not Present ❑ Other ��� ����
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO •
FORMATION
Diameter Depth Set m oversrze hole7 Annular space irntially grouled�
If nol known,indicale es�ima�ed brmalwn log from nearby well or boring. �/ ^i .�,/`
'„t ' ; � �� L/ In.from O to �S1 ft. ❑Yes I�IJo ❑Yes ❑No ❑Unknown
� ri
! 3 in.from to ft. ❑Ves ❑No ❑Yes ❑No ❑Unknown
tJ
in.from to ft. ❑Yes ❑No ❑Ves ❑No ❑Unknown
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
m.from to ft. ❑Perfora�ed ❑Removed
in.irom to ft. ❑Perforated ❑Removed
Type of perforator
❑O�her
GROUTING MATERIAL
""r- /
�J<�+i�C'G!!'1��(�' U /�, �
Grouting material, r m to yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
� from to ft. yards bags
from to ft. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑Ves o
LICENSED OR HEGISTERED CONTRACTOR CERTIFICATION
This well or bonnq was sealed in accordance with Minnesota Rules,Chapter 4725.The informahon contained in Ihis repoA is
� Irue to ihe best of my knowledge.
T)c� Stodol� W�II brillir� �o., Inc. 27272
Confractor Business Name Lrcense or Reg�strafion No.
� /i i...
i �_�-- � '� ' . ,
,, :, �—_,�. - ,��. ., _
. ' . , .� .. s . '
�:/�` -T'G�-...- �
Auf nze RepresentaGve Signature Dafe
___�� f
' .. � ..—-. . �' . .,s_:�.p:'+ - ._, ".
H .�_r . _..,_ .�
� *��� Name ol Person Sealrng Well or Bonng
-� HE-07434-01