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WELL OR BORING LOCATION MINNESOT A DEPARTMENT OF HEALTH Mlnl'!esota Well and Bonng H 18. 5255
County Name WELL AND BORING SEALING RECORD Sealing No.
Minnesota Unique Well No.
SCOt.t Mmnesota Statutes, Chapter 1031 ~..;.e.ri.:~.
Date Well or Bonng Constructed
115
21
Township Name
Prior
..Lake
Numerical Street Address or Fire Number and City of Well or BOring Location
7-25-01
Township No
Range No Section No. Fraction (sm. .. Ig.) Date Sealed
6082 150th St.
Show exact location of well or boring
in section grid with "X.
N1'
N
~-+-- ut-- u+____+_.
. , . ,
, I , I
, I I I
w uTu u-ru --~u---i--. E
-t-; ! !
.-+-- .-+-- --+---+-. T
i 1 j i J&mile
. Ln~__ --t-- nt----in. 1
L I I ---'- ---'-
S
f ImN ,
31
l<o
~.
l<o
Depth Betore Sealing
97
97
h
h Onglnal Depth
Sketch map of well or bonng AQUtFER(S)
location. showing property. .gs,ngle Aquifer 0 Multlaqulfer
hnes, roads. and bUildings
._ WELUBORING
I ( ~ater Supply Well
f 0 Env. Bore Hole
I
t-
.)\
STATIC WATER LEVEL
~easured 0 Estimated
o Monit. Well
o Other
97 h ~ below
o above land surtace
CASING TYPE(S)
~teel 0 Plastic 0 Tile 0 Other
Set in oversize hole? Annular space initially grouted? ' I
o Yes o No o Yes o No o Unknown
o Yes o No o Yes o No o Unknown
o Yes o No o Yes o No o Unknown
CASlNG(S)
Diameter
Depth
to~h
2
in. from
o
in. from
to
h
PROPERTY OWNER'S NAME
Woo<1ale Bui1ders
Property owner's mailing address if different than well location address indicated above
in. from
h
to
SCREEN/OPEN HOLE
422 We.t COUDty Rd
Nev Brighten KN 55112
WELL OWNER'S NAME
Screen from
92- to-.9..7
h. Open Hole from
to
n.
Delll1..U
Well owne(s mailing address it dinerent then property owner's address indicated above.
OBSTRUCTIONS
Qg Rods/Drop Pipe D Check Valve(s) D Debris D Fill D No Obstruction
Type of Obstructions (Describe) Pi p/liil! ..4 r' od"
Obstructions removed? Xl Yes D No Describe
PUMP
Type ai:. rOkp
~ Removed 0 Not Present 0 Other
GEOLOGICAL MATERIAL I COLOR I HARDNESS OF I FROM I TO
FORMATION
" not known, indicale _led formation log from neellly well or boring.
Drift.
METHOD USED TO SEAL ANNULAR SPACE BElWEEN 2 CASINGS, OR CASING AND BORE HOLE:
0 :II No Annular Space Exists
97 o Annular space grouted with tramie pipe
o Casing PerforationlRemoval
in. from to n. 0 Perforated 0 Removed
in. from to h. 0 Perforated 0 Removed
Type of perfora'or
n Other
GROUTING MATERIAL(S)
(One bag of .. .t a 94 Ibs., one bag of I .
., z50 Ibs.)
yards ';I begs
yards begs
yards begs
yards begs
Grouting Ma'erial Po r t lAnd
from
Q'L. to --0- n
from
to
n.
'rom
to
h.
from
to
n.
REMARKS, SOURCE OF DATA. w,N.wJLTlES IN SEAUNG
LOCAL COPY
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? D Yes ~ No How many? _
LICENSED OR REGISTERED W",., ,'.ACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information conlained in this report is
true to.the best 0' my knowledge.
aES WELL DRILLING CO
Contractor Business Name
27276
License or Regi ,.. u', . , r..,.
/
, '\
/;:'./
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.(~. "-..._"
Aulhorized Representative SigniJ/tire
0.18
H
185255
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