HomeMy WebLinkAboutWell and Boring Sealing Record
~U Oft BORING LOCATION
County Name
Minnesota Well and Boring I
Sealing No. H
WELL AND BORING SEALING RECORD Minnesota Unique No
Minnesota Statutes. Chapter 1031 or W-series No.
(leave blank II nOI knOwnl
64076
MINNESOTA DEPARTMENT OF HEALTH
T ownshtp Name
r.
Scott
I TO~7~ No I R;"7 No
SectIOn No. I FracllOll (sm. . 19.) Date Sealed
~n k~ ',. NU',. N\i4
10_h_QI;
115
Approximale Dale We"
or Bomg Conslructed
Numencal Street A_55 or Fore Number and Crty 01 Well or Borong Local_
14164 Rutgers st. NE, Prior Lake, MN. DeplhBeloreSealing
~~~_~,welorbomg fJ1' 1oca~:lCh"::=~::'
:~ :1: N:~ f = :l~g~ ~= o_
W ~ -~- -~- -~ l 1 Xb :
" : ' i :._ . . . _ . Sleet 0 PlastIC 0 Tile 0 <>tile<.
-;~ --1- -1-- -:- 1 t/uW "" 110 115
. _ . s . . ~ ~ Screenl"'!" to
~.,-~. ~ -3l OBSTRUCTlONIDEBAISIFlU
. O6SlructKJri [] Debns 0 FiI
PROPERTY OWNEA"S NAME
John Helg~son
MUong Address ~ cIiIIerenllhan propetly address tndocaled lIboWo.
GEOL HARDNESS OF
OGICAL IIATEfl\AL COLOR FORIlAJiON FROM
u not known. <ndicale estimated Ionnalion tog "om nearby well or boring.
Clay
Dirty sand
Sand
o 15
15 25
25 115
REMARKS, SOURCE OF DATA. DlFFlCULnES IN SEAUNG
Geology taken from a well near here.
Unique well number 207079~
MINN.DEPT. OF HEALTH copy I H
64076
I-fF.01.:w..o1
115
h.
It. Original Oeplh
Static Waler Level
. Accurate
o Approximate
83 II
x'
below
above land surface
II. Open Hole Irom
to
II.
T~oI~~~ 94 ft. of drop pipe & pump wir~
ObstructionlDebrislFiI remcMICf7 . Yes 0 No
PUMP
_Removed ONolI'_ 0 Other submersible
CASING .. .'
TO
Diameter 0epIh Set in oversize hole? Annular space initially grouted7
4. 2 110 Dyes .No Dyes DNo o Unknown
_ ".from _10 ~ II,
_ in. from _10 ~ II. DYes oNo DYes oNo o Unknown
_in.lrom_to~ft. Dyes oNo oVes oNo o Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, Oft CASING AND BORE HOLE:
II No Annular Space exists
o Annular space grouted with tremie pipe
o Casing PerforationlRemoval
in. from
II.
o Pertoraled 0 Removed
10
in. from
to
ft.
o Pertoraled 0 Removed
Type 01 pertorator
o Other
GROUTlNG MATERIAL
Grouting material neat cement
4
10 115 ft. _ yards ~ bags
to h. _ yards _ bags
to ft. _ yards _ bags
to ft. yards bags
from
from
from
from
UNSEALED WELLS AND BORINGS
Other unsealed wea or boring on property? 0 yes . No
UCENSED OR REGISTERED CONTftACTOft CERnFlCATlON
This weI or boring was sealed in accordance with Minnesota Rules. Chapter 4725. The information contained inlhis report is
true 10 the best 01 my knowledge.
Hartmann Well Co.
40174
Confr8cto< Business Name
.~~
Au~ RepresentatIVe Signature
License 0< RegIstration No.
10-19-95
Date
Kevin Har.tmann
Name 01 Person Sealing WeN 0< Boring