HomeMy WebLinkAboutWell Sealing Record
Date Seeled
.~';\ ) - q I () - 63 L/- 0
Minnesota Well and Boring H? Ll ? q n 7
Sealing No.
Minnesota Unique Well No.
or W-series No.
(LNve blank if no! known)
Date Well or Boring Constructed
WELL OR BORING LOCATION
County Name
~~
MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
Minnesota Statutes. Chapter 103/
Numerical Street Address or Fire Number and City of Well or Boring Location
33~6 I!M J8()X/..v/R~hk
Show exact location of well or boring N (j A Sketch map of weil or boring
in section grid with "X' ~ r, . location. showing property
N ...1 /~lines, roads, and buildings.
I'V. CASING TYPE(S)
. +. .t.. "i'-- "1--1 500 )( (' 7 5 ~ . Steel 0 Plastic 0 Tile 0 Other
.'t;nrl ~~ t ~ ""-'-''''''0.''''''''
-+- '+--~-+-'+--"~" J_ ..L " Outalde:OWellHouse
....-; II Pitless Adapter/Unit
.+ .:--.+..+ lliOx,(.~e.
. "';,~~~1.:'A a 0 Well Pit
,:... .,. ';-- -';;;f.~ ... 0 Buried
~
Township No. Range No. Section No. FractiSm ~
//1 ?-~ 10 ~i:'I'\.V'
Latitude !:!:..!t:. degrees If 1 minutes ~seconds
Longllud~degrees" '7 minutes ,. ~ ~seconds
GPS
LOCATION:
r
PROPERTY OWNER'S NAME/COMPANY NAME
Property owner's majjjng address if different than weUlocation address indicated above
~~ck-
J'1~SD ~~
~I ~.SSj7Jf
WELL OWNER'S NAME/COMPANY NAME
Well owner's mailing address if different than property owner's address indicated above
GEOLOGICAL MATERIAL I COLOR I HARDNESS ORI FROM I TO
FORMATION
If not known, indicate estimated formation log from nearby well or boring
~ I
V
~ - /2.-oc~
~
~
o
-50
7()
Jel) 136
I
I
I ~
I
REMARKS, SOURCE OF DATA, DIFFICULTIES I j SEALING
~~~~
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~(~ ?-11'11.f'l
_.....- ....;~. ..- ----, .'" CO;>Y
H242907
lI-q-oS
Ilf7
fl. Original Depth J If 7
STATIC WATER LEVEL
Depth Before Sealing
ft.
AQUIFER(S)
. Single Aquifer 0 Multlaqulfer
WELUBORING
. Water Supply Well
o Env. Bore Hole
. Measured
o Estimated
o Monil. Well
o Other
qa
ft. . below
o above land suriace
Inside: 0 Basement Offset
'"\1
('
~.l I
,-
_"::-J
NOV 2 1 2005
o Well Pit
, I
I
-./
o Buried
I : \'
-~".....'F,I>
CASING(S)
Diameter
If in. from 0
Set in oversize hole?
Annular space initially grouted?
Depth
to J J1 5 fl.
DYes aNo
o No
o Unknown
DYes
in. from
ft.
DYes
o No
o Unknown
DYes ONo
to
in. from
ft.
o No
o Unknown
DYes 0 No
DYes
to
SCREEN/OPEN HOLE
Screen from
ft.
I '1 Sto I if 7 ft.
to
Open Hole from
OBSTRUCTIONS
Il Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction
Type of Obstructions (Describe) , 3 if ~ b7!- ~ +.' ~
~~
~
Obstructions removed? II Yes 0 No
PUMP () /I . '" "
Type ~
SO. Removed 0 Not Present 0 Other
7 C. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
II) 0 . No Annuiar Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removai
Describe
in. from
ft.
o Perforated
o Removed
to
in. from
ft.
o Perforated
o Removed
to
Type of perforator
o Other
GROUTING MATERIAL(S) (One bag 01 cement = 94 Ibs., one bag 01 bentonite = 50 Ibs.)
Grouting Material ~ ~ from.3 to!.!:!.2.... ft. yards I ~_ bags
from
ft.
yards
bags
to
from
ft.
bags
yards
to
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? 0 Yes . 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
t~gew~~
308 E. ~~ ruw-~~
Contractor Business Name ~ S 60 ? I
'10 17 ~
License or Registration No.
~~
Authorizld Representative Signature
/1-18-05
Date
)(~ ")~
Name of Person Sealing Well or Boring
___ __....__. .__....l..2JD.2..e..