HomeMy WebLinkAboutwell info Minnesota Well and Boring 44840
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH SealingsNo. H
County Name WELL AND BORING SEALING RECORD Minnesota Unique No.
Minnesota Statutes.Chapter 1031 or W-series No. !i:', .
r'tel ane j.3 i n (Leave blank if not known)
Township Name Township No. Range No. Section No. Fraction(sm. •lg.) Date Sealed . Approximate Date Well
rc' i€J 117 f,= -4 1a 01" 'ti' 1ra 1 iVQ aQV 1! Q� or Boring Constructed
la
Numerical Street Address or Fire Number and City of Well or Boring Location t
t:;.• Orene 4�:a.aC.i Cl. Y:C',d mss. Orc1io ddl.,...,.w'9 depth Before Sealing .. 7 tt. Original Depth 5 7 it
Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate
in section grid with"X: • ation.sh ,, rro�operty lines
N roadsowingbuiltiir'gs,. 0 Approximate
,�,f4 b e
Single Aquifer 0 Multiaquifer ft. below above land surface
- —L CASING TYPE
W ; E
t hmik� Steel 0 Plastic 0 Tile 0 Other
I
a
S Screen from `�1 to 5 7 ft. Open Hole from to ft.
t mil J'.. --....t • i• 1. f e'f p
OBSTRUCTION/DEBRIS/FILL
PROPERTY OWNER'S NAME / lbstruclion 0 Debris 0 Fill
%,jj_c I.xu''l A t
Type of debris/obstruction ott4'"-
Mailing Address if different than property address indicated above.
Obstruction/Debris/Fill removed? 0 Yes 42 No
PUMP
❑Removed P.lot Present 0 Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring. r
drift 0
57 in.from to i) ft. ❑Yes ..)glo 0 Yes ❑No 0 Unknown
in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown
in.from to ft. ❑Yes 0 No 0 Yes 0 No ❑Unknown
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. 0 Perforated 0 Removed
- in.from to ft. 0 Perforated 0 Removed '
Type of perforator -
❑Other 1
' GROUTING MATERIAL
i t
Grouting material A1' f Cj1neWl from d to 57 ft. yards Zbags
from to - ft, yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING .
from to ft. yards bags
Grouted 2" veil 57' deep from to ft.• yards bags
2 baps cement UNSEALED WELLS AND BORINGS
4Ibs bentonite Other unsealed well or boring on property? 0 Yes o
2mem labor, rig & t grout }gam LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
pump 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.
DLi ''.:•:;:01".:01..i 11‘1"241.1.: URI:LU G U>., I .I. d rt 2
Contractor Business Name License or Registration No.
� 1I-13
'utho or;-esentative Sig'ha r e Date
LOCAL COPY H 44840Jim Antonson
Name of Person Sealing Well or Boring
HF-01434-n1