Laserfiche WebLink
� __ _ _ _ __ � <br /> � . <br /> MINNESOTA DEPARTMENT OF HFALTH M�nnesota Well and Boring „ � <br /> WELI OR BORING LOCATION � i H / <br /> WELL AND BORING SEALING RECORD Sealing No ���Q�_ 3 � ' <br /> Counry Name Minneso!a Unique No r � . <br /> Minnesota Statufes.Chapter 1031 or W-series No I <br /> ILeave blank if nut known) L_ <br /> Hvrme in � <br /> Township Name Township No. Range No Section Na Fiacuon�sm.-►Ig.) Date Sealed Date Well or Boring Construded <br /> Oroncr I18 23 31 �4-C100' S �-s <br /> Numerical Street Adtlress or Fire Number and Ciry of Well or Boring Location / / <br /> 1�� LuC� L��� A�� Ot�na 5 5 3 Depth Before Seahng ��� R. Ongmal Depth ��� n <br /> Show exact Ixafion of N�ell or bonng Sketch map of well or bonng A UIFER(S) STATIC WATER LEVEL <br /> m section grid with`X'. � � . � QrtY Single Aywfer ❑ Mulhaqwter <br /> li es,roads,and buildi gs. <br /> N WELUBORING Measured ❑ Estimated <br /> `� Water Supply Well ❑Monit.Well �2 j <br /> p,(y ❑ Env.Bo�e Hole ❑Olher _ / `� R `[_j below ❑ above land suAace <br /> Y� <br /> W —�- - -- -i-- --i-- E CASING TVPE(S) <br /> � � � � <br /> � ` <br /> � � � t <br /> ' ' I ,,;�.,r:...A..�""- ���^x-.•!,-s\ �Steel ❑ Plastic �Tile �Other <br /> �. --�- --r- -r- —�-- <br /> ' ' ' ' ,�m,�a ) <br /> --`- -j-- -�-- --�-- � , I CASING <br /> Dia e�f Depth � Set in oversize hole? Annualar space milially grouted7 <br /> S �y ,/� <br /> ��m;�� L� in.trom1E� ro� R. ❑ Yes �No ❑ ves ❑No ❑ unknown <br /> PROPERTV OWNER'S NAME in.from to H. ❑ Yes ❑No ❑ Ves ❑No ❑ Unknown <br /> JOe C � - <br /> P.operty owner's mailing address it Aifferent than well location adtlress�ndlcated above. in.hom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen irom�to ��""� tt. Open Hole from to ft. <br /> OBSTRUCTIONS �( <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �IJo Obstruction <br /> Well ownefs mailing address if diMerent than properry owner's address indicated above. Type of ObslruCtions(Describe) <br /> Obstruclions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOOICA�MATERIAL COLOR HARDNESS OF FROM TO � Removed �Not Present ❑ Other <br /> FORMATION <br /> If not krawn,indcete eslimated formatio�log from nearby well or boring. M�TJiOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 7�fi <br /> �y _ )�j t> No Annular Space Exists <br /> \,,,) �'�--'� �J '/ /� ❑ Annular space grouted with tremie pipe <br /> � ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ PeAaated ❑ Removed <br /> in.from to h. ❑ PeAorated ❑ Removed <br /> Type of peAoretor <br /> ❑ other <br /> GROUTING MATERIAL(S) <br /> Grouting Material ���'" � from � to /�� tt. yards � bags <br /> from to fl. yards bags <br /> rrom to n. yaros bags <br /> from ta_— ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordence with Minnesota Rules,Chapter 4725. The information contained in Mis repoA is <br /> - true ro[he best of my knowledge. <br /> Don Stadola Well Drillin� Co. , Inc 27172 <br /> Contractor Business Neme �� -�.�,.���-� License or Regrshafion fq. <br /> �,���, '�.,f -� �i`� ��.F-: ---Z�.�� / .,J �? > / <br /> Jfuthonied Representafive Signature Dete <br /> �. <br /> ���,��^y-.,-,, `�'i ��`r�O.�sY`.-. <br /> Name ol Person Seeling Well Jr�onng <br /> LOCALCOPY H <br /> HE-01434-04 8�98 R <br />