HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring �„� � d9 `� ��(1
County Name
WELL AND BORING SEALING RECORD Mennleso a�Unique Well No. `'+ -i l''
T� Minnesota Statutes,Chapter 103I or W-series No.
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Township Name Township No Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
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GPS LOCATION-decimal degrees(to four decimal places) / I -
Depth Before Sealing �!� ft. Original Depth ft.
Latitude Longitude_
. IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �6ingle Aqui(er ❑Multiaquifer A �/
.,rt I�1 ?�?orth �hore nf� Q�OTin 553�� WELL/BORING Measured ❑Estimated Date Measured��"�J� 1,� 1
�� Water-Supply Well ❑MoniL Well �
Show exact location of well or boring Sketch map of well or boring
in section grid with"X:' location,showing property Env.Bore Hole ❑Other _��__R. �below ❑above land surface
lines,roads,and buildings.
� N CASING TYPE(S)
- --'-----i-----`-----'-- r----'-._—_.
�teel ❑Plastic ❑Tile ❑Other
"'-""�"'"'�""''" WELLHEAD COMPLETION '
W : ; ; ; ET
� � � � --- Outside: []Well House ❑At Grade Inside: ❑Basement Offset
� � � �
'h Mi�e � �=� �Pitless Adapter/Unit ❑Buried ❑Well Pit
--:-----; � ; 1 .
r-- -----------
- ❑Buried
5 ' ❑Well Pit
❑Other
�i Mi1e� � ❑Other _
�J.,,,.c:.�.. �_�, .��.
PROPERTY O1WNER'S NAME/COMPANY NAME CASING(S)
C�[� �nil S�n Diameter � Depth � Set in oversize hole? Annular space initially grouted?
Properiy owner's mailing address if different than well bcation address indicated above ��.
'� in.from� to_��,�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME � .. . _ ., , SCREEN/OPEN HOLE
' � .� ' �` � ; / /
Well owner's mailing address it different than property owner's address indicated above Screen from1��t0 1f 4 k. Open Hole from to ft.
C��l� F.i� � � �.,'„� �'t:,� �TFiUCTIONS
Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)�L�� 4 L���
GEOLOGICAL MATERIAL COLOii HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe
FORMATION
PUMP `
If not known,indicate estimated formation log from nearby well or boring.
v_�y ` � v ��� Type
t_.�_.
❑Remaved �Not 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
in.from to ft. ❑Perforated �]Removed
Type ot Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes No TN#
GROUTING MATERIAL(S) (One bag of cement= 4 Ibs.,one bag of bentonite=50 Ibs.)
, �
Grouting Material�.�%��� from � to_��� ft. yards� bags
from to tt. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES tN 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.
�on �tQ�ola �Jell nrilling Cfl,. Inc. 1b91
Licensee Busi�ss Name License or Registration No.
�''` i/_ �7
`'r��� ,/�� ' �/ ;..,.� " ��� 1 l.c
eRffi�d Re resenfative Signatur � Certified Rep.No. Date
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3�1��0 ��.._ �`"�_..�,,_�.��_,,,�._.�-._ .
LOCAL COPY H ���`�
Name ol Person Sealing Well or Bonng , �
HE-01434-14 ID#53159 .. 5��3q -