HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
WELL OR BORING LOCATIONSealing No. H 151593
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
1 ` Minnesota Statutes,Chapter 1031 or W-series No.
/ , 4; t�. (Leave blank it not known)
Township Name Township No. Range No Section No. Fraction(sm.-w ig.) Date Sealed Date Well or Boring Constructed
t ,v
,4 `73/5-; /170' 5
Numerical Street Address or Fire Number and City of Well or Boring Location I
i t # > Depth Before Sealing ft. Original Depth I f rte- ft
Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL
in section grid with"X'' location, showing property �gl`Single Aquifer ElMultiaquder
lines,roads,and buildings. /WE
N WELL/BORING Measured ❑ Estimated
-r- — , , , _ -1 , Water Supply Well LIMonit.Well �,(
❑ Env.Bore Hole ❑Other ft. )(below Ill above land surface
W r-_-l----1 E ��/� Il/c- CASING TYPE(S) /
-'r---;----, V/ (Steel ❑ Plastic Li
LIOther
{ I j tc mile
--_�_-- i- CASING
Diller Depth Set in oversize hole" Annualar space initially grouted?
mei., n.from f to I y ft. ❑ Yes ,[,No ❑ Yes [1] l
No �J Unknown
PROPERTY OWNER'S NAME I in.from to ft. ❑ Yes r❑No ❑ Yes ❑No/'❑ Unknown
Property owner's mailing address if different than well location address indicated above in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown
)J ( ±G A- / - . '- ti SCREEN/OPEN HOLE
14\ji O ! L s A Cs I i-s, , ? Screen from to ft. Open Hole from to ft.
OBSTRUCTIONS
WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Well owner's mailing address If different than property owner's address indicated above. Type of Obstructions(Describe) t r/Cl t f. I p!!�'
Obstructions removed? ,'Yes ❑ No Describe t.1ll f1 " //( +'_7{
fl(<
PUMP TTTTTTiiiiii
Type S t4 hOlt16 i It
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO XRemoved ❑ Not Present ClOther
FORMATION
If not known,indicate estimated formation log from nearby well or boring. ET OD 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 ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)�J1
c' (
,1/1 'Ie _,
Grouting Material Irom to J17 j
(.x`-,shf
. yards bags
from to ft. yards bags
from to ft. yards bags
from to— ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS
1 /I / /e/' ir6e+111 Other unsealed and unused well or boring on property? ❑Yes )No How many?
Yti/ Iii6e OR REGISTERED CONTRACTOR CERTIFICATION
/i cl4",ihy'} f) •
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is
�,1// ( true to the best of my knowledge.
Contractor Business Name License or Registration No.
•
t - ..
Authorized Representative Signature Date
LOCAL COPY
H 151553 Name of Person Sealing Well or Boring
HE-01434-04 8/98 R