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WEll OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 09
County Name WELL AND BORING SEALING RECORD Minnesota UniqUe No
Scott Minnesota Statutes. Chapter 1031 or W-series No.
. lleave blank " noI knownl
T ownslllp Name ~;~; IR;No See;" NO'I F;~~ IS~e' ~)S Dale Sealed Approxmate Dale Well
Sprinq L 1I 10-16-95 or Ilonng Constructed
Numencal Slteet Address or Fore Number and C~y 01 Well or Bonng LocatIOn 108 108
1-6496 Duluth Ave. Prior lake. MN. Depth Belore Sealing It. Original Depth It.
Show __ 01_ orbomg }J -1' SkeICh map 01 well ::s Stalic Water Level . Accurate
.. sectIOn grid'" -X-, 1oca11on. showing properly . o Approximate
N ~J.and
I, I I , ~J~ 64 X
.-.- -,- -~- -.- . Single...... 0........- II. _ lanet sUlface
-
. I j .
-.- -..- _L_ _L CASING TYPE
W I , . , 1
. -~ I ,
-,.. -r- -,- .S1eeI o Plasllc . 0 Tile o 0Iher
1-; I I I ,i
~-
I , . I 1
-.-. -1- -..- -,- s.:-. t"'!" 1 0 3 to 108
s . ' II. Open Hole from to It.
14--'--+1 ~ 0BS1'RUCTI0NIIlBfllS/FlU.
.Obs1ruclton 0 Debns 0 Fill
PROPERTY OWNER"S NAME . .
James Cates 84 ft. of drop pipe & pump wire
Type 01 debrislobsInlclian' .
MIIo1ong Address . dilferenl than propeffy addcess _ abcM. .Yes oNo
ObsIruclionIDebill ...-ed1
PUMP
. . a RemoIIed o No! Presen! o Other Submersible
CASING
GEOLOGICAL MATERIAL COLOR ~ss OF. FROM TO .
FORMATION
0iameIer Oeplh Set in OIIefSize hole? Annular space inilially grouted?
It no! known. indicate estimated formation log from --rt>v WeI or boring.
n i rft (\ 1(\(\ ~ in.'rom ~ 10 ~ It. DYes .No DYes oNo o Unknown
__ in. from _10 _ It. DYes oNo Dyes oNo o Unknown
_in.from~to_lt. oVes oNo oVes oNo o Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
. No AMUlar Space Exists
o AMUlar space grouted with tramie pipe
o Casing PefforationlRemoval
in_ from to It. o Perforated o Removed
in. from to .It. o Perforated o Removed
Type 01 perforalor
o Other
GROUTING MATERIAL
Grouting malerial neat cement 'rom 6 10 108 It. _ yards .J.L bags
Irom to It. _ yards _ bags
,
REMARKS. SOURCE OF DATA,DlFFlCULTlES IN SEAUNG
This sealed well is in a basement 'rom 10 It. _ yards - bags
offset NOrth of the house
lrom 10 It yards bags
Geology taken from a well we dri lled UNSEALED WELlS AND BORINGS
in 1960 2 homes North from this Other UM881ed well or boring on properly? oVes aNo
above address. UCENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was seated in accordance with Minnesota Rules. Chapler 4725, The information contained in this repor1 is
true to the best 01 my knowledge.
Hartmann Well Co. 40174
Conltactor Business Name LICense or Registration No.
.~~ 11-13-95
Authonz tatwe S'9"8lure Dale
M~NN.DEPT.OF HEALTH cOPYT H 64092 Kevin Hartmann
Name of Person Seating Well or Bomg
M....... W"', ,,'" ""'"'' I
6~
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