HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I ��O�O�
County Name"
WELL AND BORING SEALING RECORD Mennlesoa�Unique Well No.
}� }� Minnesota Statutes,Chanter 1031 or W-series No.
{�•pDep i Y r (Leave blenk If not known)
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
zono 11� 23 07 �� �� �� �}
,
GPS Latitude degrees minutes seconds Depth Before Sealing �y ft. Original Depth ft.
� LOCATION: Longitude degrees minutes seconds
A IFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ]Multiaquifer ��1 ,�� /��� t
4196 l�orth Shore asi OrOAD I ris�• �/UBORING Measured [J Estimated Date Measured �f'� _ '.d'
�jWVater-Supply Well ❑Monit.Well .
Show exact location of well or boring ketch map of well or boring
in section grid with"X" location,showing property ❑Ern.Bore Hole ❑Other �ft. �below �J above land surface
lines,roads,and buildings.
N CASING TYPE(S)
� --'--- --'-----`-- ---'--
^ -`�t� Steel ❑Plastic ❑Tile ❑Other _
a\!'
--'-----�------`- --"'` WELLHEAD COMPLETION �
W ; � � : ET
� � � � Outside: ❑Well House �]At Grade Inside: �7psasement Offset �
- -------- - -- - ��
_ � � __� _ _ ;.
� � � � M'�e itless A p dUnd ❑Buried [.]Well Pit
'h � ❑P' da te "
._ --.-- --,-----.-- --:- l
❑Well Pit ❑Buried
S
❑Other
�1 Mile� ❑OthBf
PROPERTY OWNER'S NAME/COMPANY NAME CASMG(S)
Diameter� r Depth � Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different ihan well location address indicated above � /�
Z in.from�7 to�ft. �J Yes �(Vo ❑Yes ❑No ❑Unknown
76��370�41�Q 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 ii ditterent than properry owner's address indicated above SCreen ffOm �"" to � r ft. Open Hole hom to__ _ft.
- �TRUCTIONS
Rods/Drop Pipe ❑Check Valve(s) �.]Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe)r„��/L.�� i"�`„f��. d` `+�� __
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? es ❑No Describe
FORMA710N
PUMP
If not known,indicate estimated formation log from nearby well or boring.
� � Type
f []Removed [�Vot Present ❑Other „__
METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
(�lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe U Casing Perforation/Removal
in.from to _ft. ❑Perforated (J Removed
� in.from to ft. ❑Perforated [J Removed
Type ot Perforator____ . _
,_,Other_ ,._._
GROUTING MATERIAL(S) (One bag of cement=94 las.,one bag of bintonite=50 Ibs.)
Grouting Material�'C�� C��.f/�/�f/�m � to ` � ft. yards � bags
from to ft. yards bags
�. from to ft._ yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN 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.
D4H STODQLI! MFLL DBILLIW�i CO..,. IliC._ 1691
Licensee Business Name License or Registration No.
,,- ` ' _ 558 ,��� �;:X;
t 'd� �es� tative Signatu� Certified Rep.N¢ � Date
�,, �..i,'��-r._/��,,� '.
LGCP,LCGFY H �lOZO� S
Name ol Person Sealing Well or Boring
HE-01434-10 IC#140-0423 ! , sio7a '.