HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 4 6 91. 7
County Name
WELL AND BORING SEALING RECORD M nnle90 a�Unique Well No.
Minnesota Statutes, Chapter 1031 °Ba�N-s eries No.
Tow Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed
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GP L � ION- decimai egrees(to four decimal p�laces) '� �r L `
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Depth Before Seating f �/ fl. Original Depth ft.
Latitude___ Longitude__ _
AqUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaquifer
t}1F�,5 '+��,r� ,��[,Q �r� �r��,?O ���1!; WELUBORING Measured ❑Estimated Date Measured S�m� ���
' � Water-Supply Well ❑Monit.Well �
Show exact location of well or bOring Sketch map of weil or boring / �
' in section grid with"X" Iycaj�on,showing property U Env.Bore Hole ❑Other _ _�-= ft. �below ❑above land surface
� 7�ne�,roads,and buildings_....
N . -�^^-�� � . CASING TYPE(S)
_"'1""-^-------_:,.__�.�!: ` .. �t
: � � � � . --.�_...,�„��
--'------'--- --`-- --'-- '
���'� --'-----;--- ---`-- ---`-- � ELLHEAD IMPIETI N�le th _--- — — ,-_.__— —
❑P uT ❑O er
W ' ; ; ; E . I W °° ° �ECENED
______ _______ _ T Outside: ❑Well House �_)At Grade Inside: ❑Basement Offset
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"�-" I I I
� ; ; ; ; 'h M'ie itless A p r/Unrt ❑Buried �Well Pit
� ��
.
, , , , � � ❑P' da te 1 3 ZO��
--�--- --T-- ---�-----�-
� ❑Well Pit ❑Buried JUN
��Miie--{ ❑Other ❑Other
� F; " pF ORONO
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �-
�+(?[f�.'�n T_;jjl(j`!'��'j Diameter ) Depth / Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above ���
�_in.from � to��ft. ❑Yes [�Jo ❑Yes [�No n Unknown
in.from to ft ❑Yes ❑No ❑Yes '�,]No ❑Unknown
in.from to R. ❑Yes []No ❑Yes ;]No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
I /
Well owner's mailing address if different than properry owner's address indicated above Screen from���to .��:��1� fl. Open Hole from to ft.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS Ofl FROM TO Obstructions removed? ❑Yes U No Describe
FORMATION
PUMP
If not known,indicate estimated formation log from nearby well or boring.
' �/ Type
F,.J
❑Removed �Not Present ❑Other
= METHOD USEDTO SEAL ANNUTAR 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 of PeAorator
VARIANCE
Was a variance granted from the MDH for this well? �Yes No TN#
GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag of bentonite-50 Ibs.)
w� r /
Grouting Materiallv�-�%^���C1f from_�� 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.
T1nn �;tn��}�,a [dP�� �C����[}�-GE?s-. �4'1E. ����
Licensee Busmess Name �ense or Reg�strahon No.
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Certifjeo'Representative Signature �� Certified Rep.No.� Da[e
, � (,.,._,� _„�.—e�-, .I•. {'��
" 3��917 �„t,,..r � _3� _:..�
LOCAL COPY Name of Person Sealing Well or Boring �
HE-01434-14 ID#53159 ' Sn3a