HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 6 51 �
WELL OR BOR�NG LOCATION WELL AND BORING SEALING RECORD Sealing No.
County Name
�E:IIII�-'j')111 Minnesota Statutes.Cha ter 1031 Minnesota Unique No.
P or W-series No.
(Leave blank if not known)
Township Name Townsh�No. Ran�e No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
�re�n� 1 1 � �3 i� r _.
� � � � — �;s.t� 7
Numerical Street Address or Fire Number and City of Well or Boring Location � �
�1�li y 2��r�.h�ore Dri�e Orcn 9epth Betore Sealing ���a ft. Original Depth ��G ft.
Show exact location of well or boring Sketch map of well or boring A IFER(S) STATIC WATER LEVEL
in section grid wi[h"X'. �':���� location showing properry ��ngle Aquifer ❑ Multiaquifer
�����.,�ines,��buildings. �,,,/
N �'� W UBORING 1CI�Measured ❑ Estimated
� � Water Supply Well ❑Monit Well �
_ _ _T_ _l__ __ __ �r
\G�
❑ Env.Bore Hole ❑Other � ft. �elow ❑ aboveland sudace
W —�- -i-- -�-- --i— E CASING TVPE(S)
� �
�
I I I � � ��, � ����� ��.���l �Steel ❑ Plastic ❑Tile ❑ O
-'�- -�-- --;-- --;-- � ,.� - j ther '
I4 mlle jt-:. •. +
__�' '�__ �_ �__ � �� '_..._...,A.__. 1 CASING
S � Diame�� Depth � Set in oversize hole? Annualar space initially grouted?
�t mi�e—�,�e � in.from U to ��`o R. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
I
PROPERTY OWNER'S NAME in.trom to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown
tT1II1 �,:IGciT'�'
Property owner's mailing address if different than well location address indicatetl above. in.from _ to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown
SCREEWOPEN HOLE
r /
Screen from //� to �2C% ft. Open Hole from to tt.
OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME �Obsiruction ❑ Debris ❑ Fill ❑ No Obstruction
} /�
Well owner's mailing address if diflerent than property owneYs address indicated above. Type of Obstruction/Debns/Fill -..tNNE� �1/� � �r/
Obstruction/Debris/Fill removed? �Yes ❑ No
PUMP
Type
GEOLOGICAL MATERIAL COIOR HARDNESS OF FROM TO � Removed Ip�Not Present ❑ Other
FORMATION
If not known,indicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
p. �No Annular Space Exits
;..� .'i� .� i%'L�
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from to ft. ❑ Perforeted ❑ Removed
in.from to ft. ❑ PeAorated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
d r�T /� � �/, �
Grouting Matenal N C��?l�on l to� ft. yards � ba s
9
from to R. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑ 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.
i;C1iv :�'�'ODU�� 'f��:I,L DRILLIIti� CU. , IMC. 2 1 17:�
Contractor Business ame License or Registratlon No.
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uth z Represenfative$ignature Dafe
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LOCAL COPY H 12 6 516 Name ol Person�e�ling Well or Bonng
HE-01434-02 10/95R