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WELL. OR IIOfIING LOCATION ..-. . MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 6407
County N8me WELL AND BORING SEALING Hf;CORDMi~nesotaUniQue No.
Scott Minnesota Statutes. Chapter 1031 or W-senes No.
,Leave blank .. no! knOwnl
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Townshop Name TownSllop No.1 Range No. Sed2No I~Wl~N6,.'~N~ Dale sealed Appro.ornale Dale Well
SRring La e 114 22 10-20-95 or Bonng Conslructed II 1959
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Numencal SI,eet Address or F "eNumber and CIly 01 Well or Bonng Local"'" 123 123
16048 w. Ave. SE, Prior lake, MN. Depth Before Sealing It. Original Depth It.
Show _1oe*W> 01 well Qf bQnng N l' SkeICh map 01_ or ;: SIalic Water L..... . Accurllle
II lecloon grid willi -X- Iocaloon. showing poor.: . o ApproximaIe
roads. and
N m ~
, ~- 1 , 63 X
-,- -r - -,- . Single AquiIer 0....... II.
; b.eloolf llbcwe '-' ~
, I , , . .
-'"- -..- _L_ _l- CASING TYPE
W . . I I T
. , . ,
-,- -,- -r- -,- . Sleel 0 PIasIoc o Tile o Olhet
, , I . '.-
-, .
. . , , t':-- ?" ~ _..
-.7' -1- -; - -,- ~ ~xk-~. Screen t"'!" 118 123
.' . -$ ... . 10 It. Open Hole !rom .10 II.
~ ,----..j 11f'.-/' - ~ ~ OBSTAUCTIONIDE8AISIFlLI,;.
. . . ObslnlCloon 0 Oebns .0 Fill
PROPERTY OWNER"S NAIIE
Corine Gormley 102 ft. of drop pipe & jet nozzle
Maolong ~ . diIIeref!l.1han property address ondocated......... T~oI~ .
. . ObsIrucIionIOebrisIiI ren-cP . Yes DHo. . .
. ,
PUMP . ..-
. Removed o No! Presenl o Other deep well jet
CASING .. . .
GEOLOGICAL MA~.'_ COLOR. HARDNESS OF FROM TO
'. FORMATION
II no! known. ,ndicate eslimal8!l formalion log lrom nearby .... or boring. Oiari>eter 0epIIl Set in oversize hole? Annul... space initially grouted?
2 in.lrom -L 10 ~ II. Dyes .No Dyes DNo o Unknown
Sand v clav 0 30
Sand 30 131 _ in.ltom _ to _ II. Dyes DNo Dyes DNo o Unknown
_ in.lrom _10 _II. Dyes DNo Dyes DNo o Unknown
METllOO USED TO SEAL ANNULAR SPACE BETWEEN 2 C~SINGS, OR CASING AND BoRE ttOu::.
. No Annular Space Exisls
o Annular space grouted willi tremie pipe
o Casing Perforation/Removal
" in.lrom 10 II. o Perforated o Removed
in. lrom 10 II. o Perforated o Removed
Type 01 perforalor
o Other
GRDUnNG MATERIAL
Grouting malerial neat cement ltom 8 to 123 II. _ yards ~ bags
'rom 10 II. _ yards _ bags
REMARKS. SOURCE OF DATA. D1FFlCULnES IN SEALING
Geolo~b taken from a well we drilled lrom to II. _ yards _ bags
in 19 ,located 2 homes North from
this . above address. lrom 10 II. yards bags
UNSEALED WELLS AND BORINGS
Other unsealed weI or boring on PRlPl'flY? Dyes .No
UCENSED OR REGISTERED CONTRACTOR CERnFlCAllON
This weI or boring was sealed in accordance with Minnesota Rules, Chapler 4725. The information contained in thIS report is
true 10 \he best of my knowledge.
Hartmann Well Co. 40174
ConIrIlCfor Business Name LicenSe 01" Reglstralion No
.~.~ 11-13-95
Ault10rized a'NfI Signature Dale
MlNNJ)EPT. OF HEALTH COP~ ., 64075 Kevin Hartmann
Name of Person seating WeR or Bonng
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