HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
County Name
WELL AND BORING SEALING RECORD Sealing No. H � �. O O 6 O
Minnesota Unique No.
Minnesota Statutes,Chapter 1031 or W-series No.
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Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
't i,. % % '/a �� .�. .._. �-'� � �� �% ���� .
Numerical Street Address or Fire Number and Ciry of Well or Boring Location
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.--;.,�,j '�``, . , k� -� Depth Before Sealing � � i� ft. Original Depth � -�-7 ft.
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Show exact location of well or boring 'Sketch map of well or boring ppUIFER(S) STATIC WATER LEVEL
in section grid with"X". location, showing property Single Aquifer ❑ Multiaquifer
lines,roads,and buildings.
N WELUBORING [}�dvleasured ❑ Estimated
� � � � -�"�'��'"��'� [[�Water Suppty Well ❑Monit.Well
_T_ _T_ _l__ __l__ /�, �t J
N`t `\ Env.Bore Hole Other r � ft. below
❑ ❑ � ❑ above land surface
� � � � � i
yy -� -r� --� �-'-- E `�, W�'� CASING TYPE(S) �
� � � � ' 7 �� .
� , , � � ��
'-�- -�-- --�-- --�-- � } �Steel ❑ Plastic ❑Tile ❑Other
1G mile l
-�-- -i-- -�-- --�-- � \ CASING
Diameter Depth Set in oversize hole? Annualar space initially grouted?
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�t mae—��e _ � in.from�_ to � '_r_�_7._ ft. ❑Yes [�No ❑ Yes ❑No �Unknown
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PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
u✓ Nn<: �C.�. ��:_
Property owner's mailing address if different than well location address indirated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown
� SCREEWOPEN HOLE
•-�1 L4 �°-�r: i �V. .
1 , ( k l M� �! �_ Screen from to R. Open Hole from to ft.
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OBSTRUCTIO WDEBRIS/FILL
WELL OWNER'S NAME Q'Obstruction ❑ Debris ❑ Fill ❑ No Obstruction
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Well owner's mailing address if diNerent than property owner's address indicated above. Type of Obstruction/Debris/Fill ���✓�-�• �� a';•3..'' �� ���-
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Obstruction/Debris/Fill removed? � Yes ❑ No
PUMP
Type , = �
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other
FORMATION
If not known,indicate estimated formation log trom nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
� � 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)
Groutin Material - ' from ,
g _ � to�� ft. yards � bags
from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFPICULTIES IN SEALING UNSEALED WELLS AND BORINGS � t j
(r�.Jt�� �" ""} �
Other unsealed well or boring on property? Yes� No '
� LICENSED OR REGISTERED CONTRACT CE 71FICATION
� � � �,,.��_ i t �` , � -
�� . 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.
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Conhactor Business Name License or Registration No.
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Authorized Representafive Signature �, Date
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���. �-=. � � 1 Y " � � �� ����"l
�q (� Name o/Person Sealing ell or Boring
LOCAL COPY H � 1. � O U O
HE-01434-02 10/95R