Laserfiche WebLink
MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring ��� !�n —_� <br /> EL�OR BORING LOCATION I <br /> ���N Name — WELL AND BORING SEALING RECORD Sealing No. �H +cf 3 <br /> Minnesota Unique Well No. r <br /> H����i� Mmnesota Sfatutes.Chapter 1031 or W-series No. II J <br /> �Laeve daiNc X nd kmwn) L_ <br /> Township Name Township No. Range No Sechon No. FracUon(sm.i Ig.) Date Sealed Date Well or Bonng Constructed <br /> �'QTi� �.�+� �� 2� ,. ,. <br /> Numerical Street Address or Fi�e Number and Gry of Well or Bonng Locauon t ^s <br /> 28Q5 bth Ave. North, LOl2� �r$�� Depth Before Sealing j�i N Original Depth ft <br /> i Show exact location of v.�ell or bonng `Sketch map of well or boring ApUIFER�S) STATIC WATER IEVEL <br /> in section gnd wrth"X". location, showing property �ingle Aywfer � Multiaqwfer <br /> i lines,roads,and buildings. <br /> ry WELUBORING �Measuretl ❑ Estimated <br /> i � � � � �Water Supply Well ❑Monit Well <br /> —�- -i— --;-- —� p� <br /> . ❑ Env.Bore Hole ❑Other q!.—ft. [�below ❑ above land surface <br />(„�:; . w -�- -i-- -i— --;— E CASING TYPE�S) <br /> � � , � <br /> �� -;-- -i-- --;-- --�— � [�Steel ❑ Plastic �Tile ❑Other <br /> }4mile <br /> —`- ---- -�— --�-- � CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> S <br /> �I(.--i m��e��'. � in trom� ro 1�� tt ❑ Yes �No ❑ ves ❑No (�Unknown <br /> PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> P�operty ownei s mailing address if different than well location address Indicated above in.from to ft. ❑ Ye5 ❑ No ❑ Yes ❑No ❑ Unknown <br /> - �,�5� V.t� AD'�. ATb.L•�h SCREEWOPEN HOLE * <br /> LiG.�'Qg��-.�i�� � >.lJJ6 Screen from ��� to j�� ft. Open Hole from to tt. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction <br /> Well owner's mailing address it CiBerent than properry owner's atldress indicated above. Type of ObstruCtions(Describe) � <br /> Obstrudions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> QEOL061CAL MATERIAL COLOR HARDNESS OF FROM TO �Removed ❑ Not Present ❑ Other <br /> � FORMATION � <br /> If not known,iMicate estimated tortnation log from nearDy well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> L7No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to h. ❑ Perforaled ❑ Removed <br /> in.from �o ry, ❑ Perforated ❑ Removed <br />��- Type of perforator <br /> ❑ other <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=501bs.) <br />- Grouting Material �8gt C'���� from � to 1�7 R. yards �� bags <br /> S <br /> from to R. yards bags <br /> from to ft. yards bags <br /> - from to__ 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 �,.J No How many? <br /> � UCENSED OR RECa1STERED CONTRACTOR CERTIFICATION � <br /> This well or bonng 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 /> Stevena Drilli�g � 8nv. Serv�.ces. Inc, 8fi654 <br />� Contractor Business Name ' �" License a Registrahon I'a. <br /> ����� <br /> Authorized Representative Signature Dete <br /> Rs.ndy 3ohnsa� ol/�s1U� <br /> H 16 3 4 5 3 Name ol Person Sealing Well or Boring <br />