Laserfiche WebLink
� <br /> wELL OR BOR�NG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �F�� �� <br /> Counry Name <br /> WELL AND BORING SEALING RECORD M nnlesoNa Unique Well No. L <br /> � i� Minnesota Statutes,Chapter 1031 or W-series No. <br /> 0.��aeok n�m k�own� <br /> Township Name Township No. Ranc�e No. Section No. Fraction(sm-�Ig) Date Sealed Date Well or Boring Constructed <br /> C#rar� 17 23 f)6 �,. �,. �,. <br /> GPS Latitude degrees minu[es seconds ,� <br /> LOCATION: Depth Before Sealing ft. Original Depth tt. <br /> Longitude degrees minutes seconds p UIFER(S) - STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and Cily of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> W LLBORING �Measured ❑Estimated <br /> 7� A � � Water Supply Well ❑Monit.Well ( <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" bcation,showing property ❑Env.Bore Hole ❑Other ��ft. below ❑above land surface <br /> N ,and buildings. CASING TYPE(S) <br /> - - - - - -- - -- '+ � <br /> � Steel ❑Plastic ❑Tile ❑Other <br /> W --�- - — - -- --i-- E � WELLHEAD COMPLETION <br /> � � � Outside: ❑Well House Inside:�Basement Offset <br /> -;-- ---- -r- -i-- <br /> !�� ❑Pitless Adapter/Unit ❑Well Pit <br /> —�- -�-- -�-- --i-- I <br /> 1 ❑Well Pit ❑Buried <br /> �—""i1°—�' �{f , ❑Buried <br /> /:J '�..�J;.%ft�a _ . <br /> ��� PRLO�PERTYt OWtN�.E,,Rw'S�NAME1/�COMPANY NAME CASING(S) <br /> i'�1�i ln.�ll� 1� Diameter Depth � Set in oversize hole? Annular space initially grouted? <br /> PropeAy owner's mailing address'rf di8erent than well location address indicated above �� <br /> � in.from� t0��ft. ❑Yes �No ❑Yes ❑No ❑Unknown <br /> 1315 �iarns St, Ste 1 <br /> a7tiG.R�}�� MN 55379 in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffom to ft. ❑Yes ❑No ❑Yes ❑No � ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � <br /> �/�/ <br /> We��owner's mailing address it different than properry owners address indicated above Sc�een f�Orp�S„dL—to_��ft. Open Hole frOn1 t0 ft. <br /> i, OBSTRUCTIONS <br /> ` Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction ' <br /> � � r/•-- <br /> ; � �� <br /> Type of Obstructions(Describe)�bS+�y!�_��''��f 4 l! � / <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ No Desc�ibe <br /> FORMATION <br /> If not known,indicate estimated formation log irom nearby well or boring PUMP <br /> , Type <br /> 1J <br /> � ❑ Removed �Not Present ❑Other <br /> f METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PeAoration/Removal <br /> in.from to ft. ❑ Pertorated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonRe=50 Ibs.) <br /> ( <br /> Grouting Matenal� �m�_to� yards � bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING 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 accordance with Minnesota Rules,Chapter 4725.The information-contained in this report is <br /> - true to the best of my knowledge. <br /> T1on Stodala '6�I1 Drii i <br /> Contractor Business Name � License or Regisha6on No. <br /> _ D'� <br /> h en ive nature/ Date <br /> LOCALCOPY <br /> H2�6757 "� �'�°'�' <br /> Name ol Person Sealing Well or Boring <br />