HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10253 5
County Name
WELL AND BORING SEALING RECORD Sealing
Minnesota
Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm.,i Ig.) Date Sealed Date Well or Boring Constructed
!14 V4 Y4
Numerical Street Address or Fire Number and City of Well or Boring location
C
Depth Before Sealing 1 Ll ft. Original Depth
Show exact location of well or boring S etch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with X.. location, showing property U.Single Aquifer ❑ Multiaquifer
N „9
lines,roads,and buildings. DEC .� l�.WELL/BORING
Measured Estimated
❑Water Supply Well ❑Mont.Well
❑ Env.Bore Hole ❑Other ft. L�(below ❑ above land surface
Vy --�- -�-- --�-- --i-- EN CASING TYPE'S)
, -�
--�- --I-- --�-- --i--
IS
E] Plastic ❑Tile E]Other
'/.mile -_— j
--I-- - -- --�-- --d-- �`'�... CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
S
p�t mile s "---^- Y in.from to 'Y ft. ❑ Yes Ufio E] Yes E]No PcjJnknown
I t
PROPERTY OWNER'S NAME __ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
I y:
Property owner's mailing address if different fiinnwelf location address indicated abovein.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
SCREEN/OPEN HOLE
Screen from to ft. Open Hole from to ft.
OBSTRUCTION/DEBRIS/FILL
WELL OWNER'S NAME [ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
t 11
Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill f
Obstruction/Debris/Fill removed? L .Yes ❑ No
PUMP
Type j
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO El Removed [3,Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
5(No Annular Space Exits
❑ Annular space grouted with tremie pipe
❑ Casing Perforation/Removal
in.from_ to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)
r .
Grouting Material t L from �. to ft. yards bags
from to ft. 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
i
true to the best of my knowledge.
_ Contractor Business Name License or Registration No.
Authorized Representative Signature Date
LOCAL COPY
H 1 0 2 535 Name of Person Sealing Well or Boring
HE-01434-02 10/95R