HomeMy WebLinkAboutWell Sealing Record
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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