HomeMy WebLinkAboutwell info WELL oR BORING LOCaTION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I ��A���
County Name
WELL AND BORING SEALING RECORD M nn'eso a�Unique Well No. L"
�� Minnesota Statutes,Chapter f031 or W-series No.
��0a.a ae�k a oo�ww��
Township Name Township No. Range No. Sec[bn No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
nroc� 217 23 Zl 29 ',. '"�
GPS LaGtude degrees minutes seconds � �
LOCATION: Depth Before Sealing �� ft. Original Depth � ft.
Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL
Numerical Sheet Address or Fire Number and City of Well or Boring Location Single Aquiter ❑Multiaquifer
WELUBORING Measured ❑Estimated
Water Supply Well ❑Monft.Well �
Show exad location of well or boring Sketch map of well or boring //
in section gnd with"X" location,showin roperty ❑Env.Bore Hole ❑Other �ft. �below ❑above land surface
N �.� liqes,ro a uGd ings.
'---a.,.," +;;�1:.;..�r��' �!J� CASING TYPE(S)
�����, Steel ❑Plastic ❑Tile ❑Other
W —�- - — -;-- --;-- E ....----"""" WELLHEAD COMPLETION
� � � � Outsfde: ❑Well House Inside: ❑Basement Otfset
--i-- ---- -;-- -i— �
�^� �(Pitless AdaptedUnit ❑Well Pit
—�- -�- -�-- --i-- I
1 ❑Well Pit ❑Buried
S
�—""'�'—�' ❑Buried
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
Dia t�r� Depth l Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above f�
� in.ffom" to�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown
if1.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOL�Ej f
Well owner's mailing address it different than property owner's address indicated above Screen from � • t0�/ft. Open Hole from t0 ft.
OBSTRUCTIONS
�' Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) ..����./�(� �rP� �' ��/'�6✓
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObstructionS removed? YeS ❑ NO DeSCribe
FORMATION
If not known,indicate estimated formeUon log from nearby well or boring PUMP
j �., . Type,� U �J
�f` Removed� ❑ Not Present ❑Other
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 PeAoration/Removal
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonRe=50 Ibs.) �^'] `'�
Grouting Material/"�"��� C'�lCJ��from � to�._ft. yards v 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 infortnation contained in this report is
true to the best of my knowledge.
Do�n Stodals T�el I I3rillin� Gt�,. Inc. 27172
Contractor Business N me License or Registra6on No.
� � '�...% ` l t� �v
A n e 'gnature � Date
LOCAL COPY
H 3 2�5 9 - .,�� ;,,�..����..
Name ol Person Sealing Well or Boring