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HomeMy WebLinkAboutWell & Boring Sealing Record 9.11.15 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 319461 CELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. / J�9 County Name Minnesota Unique Well No. ?W 9V Minnesota Statutes,Chapter 1031 or W-series No. P (Leave blank if not known) wnship Name Township No. Range No. Section No. Fraction(sm.-.1g.) Date Sealed Date Well or Boring Constructed ndet.�,� I 1 I" aaN nk►h PA s i �(a 1t i 5— 9 -))- I S--/ GPS LOCATION-decimal degrees(to four decimal places) �/� A40 Depth Before Sealing I"' ft. Original Depth ft. Latitude Longitude UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 1� WELLBORING ❑Measured El Estimated Date Measured cL b e- It \••0t.04- ReJ\ ��Crt�tZ1.►� ..-- ❑Water-Supply Well ❑Monit.Well Show exact location of well or boring a----I------=--- lSokceattcohnmsaphisf'i9 n9 ❑ Env.Bore Hole je O th ),�l / 1101 ft. El below ❑above land surface in section grid with"X°NI.' lines,roads,an udgCASING TYPE(S) ......_ —_ _________.___ lt� Vg, 04 Steel ❑PIastic ❑TIle ❑Other LWELLHEAD COMPLETION W E E , • Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h milk, ❑Pitless Adapter/Unit ❑Buried ❑Well Pit _T-_ T x ^ x i '.. r OL ❑Well Pit ❑Buried s ❑Other — 1 Mile —I )L C*. � YOther lc))) ctOtAlt �bJ� - P OPERTY OWNER'S NAME/COMPANY NAME CASING(S) 11 tbe, LAAlt,.. Diameter Depth ter Set in oversize hole? Annular space initially grouted? l Property owner's mailing address if.different than wet location address indicated above I V in.from © d to 2 ft. ,.Yes ❑No ❑Yes 'No ❑Unknown yt6Log, OokbTa 51Itter 34— in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Pri-64. L '&L MN in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown LL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Yr/4)Z L At0.-- Screen from .23 to 9i" ft. Open Hole from to ft. Well owner's mailing address if different than property owner's address indicated above -OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill No Obstruction Type of Obstructions(Describe) !�"�� GEOLOGICAL MATERIAL COLOR HARDNESS RRMA OOR FROM TO Obstructions removed? ❑Yes El No Describe PUMP If not known,indicate estimated formation log from nearby well or boring. i3 yt ❑ s 0"lb Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe Casing Perforation/Removal✓ Ib. in.from b to a 3 ft. ❑Perforated IIXI Removed in.from to ft. ❑Perforated ❑111 Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? El Yes Ir<No TN# GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Material 5CIVIIS era1Ib-S from 0 to g ft. yards bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes l<No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. „� fl 1111 1'11 etAIP .,7 mac_ : 1 3)S' Licensee Business Name License or Registration No. 313y 41.2?IIS' Certi red Representative Signature Certified Rep.No. Da IMPORTANT-FILE VNTH PROPERTY H 31 9 4 6 1 Z- 11 PAPERS-WELL OWNER COPY Name of Person Sealing Well or Boring HE-01434-14 IC#140-0423 5/13R