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HomeMy WebLinkAboutWell Sealing Record , WELL OR BORING LOCATION Counry Name ~ MINNESOTA DEPARTMENT OF HEALTH WELL AND BORING SEALING RECORD Mlnn..o" S,.tute., Ch.ptef 1031 Minnesota Well and Boring Sealing No. Minnesota Unique Well No. or W.series No. (LMw tMnk It noc known) \H ?L1?qnl I Township Name ~ Township No. lIS Rano' No. SectJon No. ~on ~+ )(; Oat. S.alad ?-j... 36 w e. t.V' /I-Cf--O.s- Date Well or Boring Constructed I Cf 70 '08 longitu08 degr... minute. seconds NumencaJ Street Address )!l..Fire Number and Clry of Well or Boring Localion 51).. CJ 0 ~ .I'~ ~SIE. Show exac1 lOCation of well or b<lrinQ ~ ~ ~ Sketch map of well or botIng in sectJOn grid with 'X' ~~ 7-r?-f~ 'MlJpn. showing property HK'.~uu;.r 1,--'''''"'1 ""'"""'''~I l: : :~: H 0 ~.sE ( wrT"TI~"~" E 4.-~ '+j+' , T A J ~ ~ Outside: 0 Well House +"':" .:.....:.. l"!.V () I I ,/~~.:t::t . Pitle..AdaplerlUnit ...:....t.S.1'.-.t (('~~. o Well Pit r ,- l' -7 -L- .P~ s. Buried ~ Cv4:4 r E. PROPERTY OWNER'S NAME/COMPANV NAME CASING(S) Dia~,ter prfr~'g=~ve '1' in,from I / 7S95 X~vv..L ~ in. from ~u.-~ h1.., !J'SO~~::z..Cj" WELL OWNER'S NAME/COMPANV NAME GPS LOCATION: Latitude second. degr... mlnut.. W~ owner's mailing addr... if differenl than property owner's addr.u indicated abov. GEOLOGICAL MATERIAL I COLOR IHARDNESS ORI FROM I TO FORMATION II noIknown. indicat. eabmal8d formation IoQ from neSItly waU or borinQ ~ ~ ~ 'W~~ o /0 1-0 JOO I J ~ ~ 1;1. Se> 7" b 7 3 If REMARKS, SOURCE OF DATA. DIFFICULTIES IN SEAUNG ~~~a,... ~~~,~~ ~ ?-07J.f/o ,.c..-';" r t' L:QP'f H242903 Depth Before Sealing .--1 0 8 AQUIFER(S) . Single Aquifer 0 Multiequller WELLJBORING . Water Supply Well 0 Monit. Well o Env. Bore Hole ft~ Original Depth ft. STATIC WATER LEVEL . Measured 0 Estimated 3!J ',,\: o Other ft. . below o above land surlace . Steel 0 Plastic Ollie 0 Other WELLHEAD COMPLETION Inside: 0 Basement Offset o Well Pit o Burled Depth to I () 8 ft. Set in oversize hole? Annular space Initially grouted? .No o Ves o Ves o No o Unknown to ft. o No o Unknown o Ves o Ves o No in. from ft. o No o Ves o No o Unknown o Ves to SCREEN/OPEN HOLE Screen from ft. Open Hole from to 108 ft to OBSTRUCTIONS . Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction Type ot Obstructions (Describe) ~-t..Lt- ~ ~ ~. ~ ~ ~ , --,--., , I , Obstructions removed? . Yes 0 No Describe ~, PUMP ,. / _ _.' I /J Type~/ J 0 . Removed 0 Not Present 0 Other ,.. 0 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: I 00 . No Annuiar Space Exists 0 Annular space grouted with Iremie pipe 0 Casing PerloraliorVRemoval in. from to ft. 0 Perlorated 0 Removed in. from ft. o Perlorated o Removed to Type of perlorator o Other GROUTING MATERIAL(S) (One bag 01 cement. 114 lb.., on. bag 01 benton It. = 50 lbs.) Grouting Material .~ ~m ').. to J 0 8 ft yards J 8 bags from ft. yards bags to from ft. yards to bags OTHER WELLS AND BORINGS Other un..sled and unu..d well or boring on property? 0 Ves. . No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION Thl. well or boring was ..aled In accordance with Minnesota Rule., Chapter 4725. The information contained in thiS report IS ~ W..eP ~ 30R E~ ~~ h.ew--r>~ )4-0/'7/-f Contractof Business Name ~ ~ 6 0 71 'License or F{egIS(fa(lOn No. ~en~ 11--18-0S- Date /(~ )~ Name of Person Sealing Well or Boring