HomeMy WebLinkAboutwell info Minnesota Well and Boring H 4 9 0 8 4
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealinq No.
�o���y Name WELL AND BORING SEALING RECORD M���esota un�q�e No.
Minnesota Statutes.Chapter 103/ or W-series No.
F��� �Leave blank if nol known�
Township Name Township Na Fange No. Section No. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
�w ��� 23 �� ��,4 � or Boring Constructed
V�V11iJ
Numencal Street Address or Fire Number and Ciry of Well or Bonng Location � i t /
27V1 �e •�*+�LC LLi.nAl 55331 Depth Before Sealing ��t� fl Original Depth �-�`�1 Fl
Show exacl location of well or bonng Sketch map of well or boring Static Water Level Accurate
in secUon gnd with��X��. locahon,showing property lines.
N i - roads.and buildings. ❑Approximate
i i i i , �
-� -i- -i- -i -:`t .
.,� ` ingle Aquifer ❑Multiaquifer �fl. -� below above land surface
i i i i +V
_i_ _a_ _�_ _i_ CASING TYPE
W i i i i E
� � � � T
-r -�- -r- -r �`
i i i � Steel ❑Plastic ❑Tile ❑Other
mile
_i_ _i_ _i_ _i_ � . J �^_.:`�� ,
- � t ���1 � l
S ; Screen from � to fL Open Hole from to ft.
N-i mi�e-� ��-�^------ �3' OBSTRUCTION/DEBRIS/FILL
��
P OPERTY O N R'S NAME �,Obsiruc[ion ❑Debris ❑Fill'
�eis�c�t �r�isi 471-9001 /� / �f^�f
Type of debris/obsVuction ��J�!'���"�� � ` L/'`��
Mailing Address d drfferent than property address indicated above.
ObsVuction/Debris/Fill removed? (�Ves ❑No
PUMP
Removed ❑Not Present ❑ Other ����'�7 •'�r'�+
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depih Set in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or bonng. � '
/
�
drift O �in from �to ��.�j ft ❑Yes �lo ❑Yes ❑No ❑Unknown
� in.from to f�. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to R. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�IVo Annular Space Exists
❑Annular space grouted with iremie pipe
❑Casing Perforetion/Removal
in.from to fl. ❑Perforated ❑Removed
in.from to tL ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATEiiIAL
�r �,// /
� Groutingmaterial�Aff�f ���from ��o G�G• ft, yards li-? bags
from to fl yards bags
REMARKS,SOURCE Of DATA,DIFFICULTIES IN SEALING
from to ft. yards bags
from to tt. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property? ❑Yes o
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance wi�h Minnesota Rules,Chapter 4725.The information contained in this report is
irue to ihe best of my knowledge.
Don Stodola Well Drillir� Co., In�. 27172
Contractor Business Name . . License or Registration No.
� :
.�,'',,'- /� �� 3-4-�44
r r
�uth'�presentativeSrgnaTu"re�� Date
���A����� H 4 9 0 8 4 J�, �t� .
Name ol Person Sealing Well or Boring
� H601434-01