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