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HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 3 4 6 9 1 9 WELL OR BORING LOCATION Sealing No. H County Name z WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. 1 t:it it C:(�1 ii P (Leave mask a no known) ..,/ . / Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed vraetp 217 d.i 17 ' v ., . ._. ..i,: 5/5-/i7 GPS LOCATION—decimal degrees(to four decimal places) / 0 f Depth Before Sealing /‘ ft. Original Depth ft. Latitude Longitude A UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ,�1 /�,/�y.,/ W L/BORING -X Measured ❑Estimated Date Measured T/-;'�l4 r}/4/ ,1 )i I LILL.V` t h V`: U r fa n© • Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or oring �? in section grid with"X." location,showing prop rty ❑Env.Bore Hole ❑Other EJ ft. )4 below ❑above land surface lines,roads,and buildi g N CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other ---I------I-----'t----'-"' 11,, WELLHEAD COMPLETION w : E } T_ __ I 141 7 Outside: ❑Well House ❑At Grade Inside: Basement Offset h Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit RECEIVED --- - ---------- - - 1 ❑Well Pit ❑Buried I 1 Mile ❑Other ❑Other juN 13 2011 PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Jd Dia e;ero f Depth 5'7 f Set in oversize hole'? t' rO IF-(jt h/' 'Qi d? Property owner's mai?fr ad esslf dl erert�'4han well location address indicated above in.from (1 to l ft. ❑Yes )(No ❑Yes ❑No ❑Unknown G i 10 J it e a y r 1 il e £,J2 a e in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown rueathaoiiie, WI. 54751 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE s / I Well owner's mailing address if different than property owner's address indicated above Screen from F ;0/ Well ft. Open Hole from to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe)..._,/L/AJ4'S/< ,01-1*.. i UM� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Xes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. [('�� nj////^���� / Type �e �mf , 6 /(L$/ Vemoved ❑Not Present ElOther 1 METHOD 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 VARIANCE Was a variance granted from the MDH for this well? ❑Yes j��, No TN# GROUTING MATERIAL(S) (One bag of cement w 54 lbs.,one bag of bentonite=50 lbs.) P f w� Grouting Material f�r4.476144 from to /4 1 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. .1..“../.1 ,...,1u✓i)I.IA 41,1_444 uK.ZL141.jYLr t..:.J• , .L G• 107'1 Licensee Business flame License or Registration No. i / tertified eR p�ntative Signature Certified Rep.No. Date " 346919 a ,� �- -0 LOCAL COPY 1 Name of Person Sealing Well or Bc HE-01434-14 1D#53159 5/13R