HomeMy WebLinkAboutwell info Minnesota Well and Boring ��O ^ �
�� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H ��
�o���Y Name ` WELL AND BORING SEALWG RECORD M���esota u��q�e No.
� Minnesota Statutes.Chapter 103/ or W-series No.
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Township Name Township No. Range No. Section No. Fraction(sm. �Ig.) Date Sealed Approzimate Date Well
j ,.. or Bonng Constructed .
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Numencal Street Address or Fire Number and City of Well or Boring Location
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-. � : ,�. ��}� ��„ "�. r � l n V Depth Before Sealing ��� f�. Original Depih ft.
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Show exact location of well or bonng Ske�ch map of well or boring Static Water Level �Accurate
m section grid wdh��X��. location.showing property lines.
roads.and buildings. ❑Approximate
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�..Single Aquifer ❑MWtiaqwfer ft. below above land suAace
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_i_ _�_ _i_ _i_ `-�- CASING TVPE
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-r -�- -r- -r j
� � � � mile . (j,�,! � �-Steel ❑Plastic ❑Tile ❑Other
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-i i -i- i ��: i-r- � _...
S � � �,..... Screen from to ft Open Hole from to ft.
�-i mile-� OBSTRUCTION/DEBRIS/FILL
�ObsVuction ❑Debris ❑Fill
PROPERTY OWNER'S NAME
) Type of debris/obs�ruction 1� �1
Maiting Address d different than property address indicated above. �
Obstruction/Debris/Fill removed? �Yes ❑No
PUMP
�Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FHOM TO
FORMATION
Diameter Depth Se�in oversize hole? Annular space irntially grouted?
If not known,indicate estimated formation log hom nearby well or boring.
\
`J�J / iQ in.from to ft. ❑Yes �No ❑Yes ❑No ❑Unknown
! q.
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑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
in.from to fl. ❑Perforated ❑Removed
in.from to ft. ❑Perfora�ed ❑Removed
Type of perforator
❑Other
GROUTING MATEHIAL
Grouting material P�. � � from to � ft. yards � � bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
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� irom to ft yards bags
UNSEALED WELLS AND BORINGS
� , � O�her unsealed well or boring on property7 ❑Yes �,No
� 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.
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Contractor Business Name License or Registration No.
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Authorized ReprBsentative Signature� Date
58049 ` ' �
LOCALCOPY H '
Name ol Person SeaOng Well or Bonng
HE-01434-01