Laserfiche WebLink
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10253 5 <br /> County Name <br /> WELL AND BORING SEALING RECORD Sealing <br /> Minnesota <br /> Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.,i Ig.) Date Sealed Date Well or Boring Constructed <br /> !14 V4 Y4 <br /> Numerical Street Address or Fire Number and City of Well or Boring location <br /> C <br /> Depth Before Sealing 1 Ll ft. Original Depth <br /> Show exact location of well or boring S etch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with X.. location, showing property U.Single Aquifer ❑ Multiaquifer <br /> N „9 <br /> lines,roads,and buildings. DEC .� l�.WELL/BORING <br /> Measured Estimated <br /> ❑Water Supply Well ❑Mont.Well <br /> ❑ Env.Bore Hole ❑Other ft. L�(below ❑ above land surface <br /> Vy --�- -�-- --�-- --i-- EN CASING TYPE'S) <br /> , -� <br /> --�- --I-- --�-- --i-- <br /> IS <br /> E] Plastic ❑Tile E]Other <br /> '/.mile -_— j <br /> --I-- - -- --�-- --d-- �`'�... CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> S <br /> p�t mile s "---^- Y in.from to 'Y ft. ❑ Yes Ufio E] Yes E]No PcjJnknown <br /> I t <br /> PROPERTY OWNER'S NAME __ in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> I y: <br /> Property owner's mailing address if different fiinnwelf location address indicated abovein.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME [ Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> t 11 <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill f <br /> Obstruction/Debris/Fill removed? L .Yes ❑ No <br /> PUMP <br /> Type j <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO El Removed [3,Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 5(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 /> r . <br /> Grouting Material t L from �. 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,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes No <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 /> i <br /> true to the best of my knowledge. <br /> _ Contractor Business Name License or Registration No. <br /> Authorized Representative Signature Date <br /> LOCAL COPY <br /> H 1 0 2 535 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />