HomeMy WebLinkAbout2017-02-15 Well and Boring Sealing Record MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring "1 t "- CA
WELL OR BORING LOCATION Sealing No. H k 3!
County Name WELL AND BORING SEALING RECORD Minneave sotail runque Well No. 9
Minnesota Statutes,Chapter 1031 or W-series No. t 'i
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Town hip Name To 4 hip No. Range No.Section No. Fraction(sm..— Ig.) Dale Sealed'`' Date Well or Boring Constructed
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GPS LOCATION decimal degrees(to four decimal places)
45
Depth Before Sealing It Original Depth ft.
Latitude_._ Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquiler
�j Q'� c. A WE Water-Supply
Measured ❑Estimated Date Measured 1
5 v(' a-' ^d/r�r' SV t fr rtf-� W Water-Supply Well ❑Monit.Well
Show exact location of well or boring Sketch map of well or ing
in section grid with"X" location,showing prod ty ❑Env.Bore Hole ❑Other It. [below ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
10 Steel ❑Plastic ❑Tile ❑Other _
WELLHEAD COMPLETION
w , T1.----"\
i__ __r___ ;__ Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
'4 Mile KPiIless Adapter/Unit Li Buried ❑Well Pit
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s
❑Well Pit ❑Buried
❑Other
1 I Mile I - LiOther
siN.-1 StI _ri
PaGPERTY OWNER'S NAM COMPANY NAME CASING(S)
WI, „ Diameter Depth Set
Set In oversize hole? Annular space initially grouted?
Property owner's mailing''daaddress II different than well location address indicated above ,Q in.from d to T t) ft. ❑Yes ,No ❑Yes ID No ❑Unknown
S8 c , SI-
�/��tx�` in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
Sb I / � 5`5 01 2—
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE4/1'�
�
Well owner's mailing address if different than property owner's address indicated above Screen from to h. Open Hole from r lJ to fl.
OBSTRUCTIONS
❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill $No Obstruction
Type of Obstructions(Describe)--
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe
FORMATION
PUMP
II not known,indicate estimated formation log from nearby well or boring. !� r) e, (�)
.s� v�� Type Vtdt`��m�a,J1 bie,
�'4t .gatt`'tet ,C&(•e,C( p 40 1]Removed ❑Not Present ❑Other
,(a (�j1 C�,r f(Lr'1Tkl 'Llo 4.3 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
54 No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
in.from to ft. ❑Perforated ❑Removed
in.from to ft. U Perforated ❑Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this wet? ❑Yes ANo TN#_,____
GROUTING MATERIAL(S)/ ,,`�t (One beg of cement=94 lbs.,onee begbof bentonite=50 lbs.)
Grouting Materiall,rv'�, n `'`'t from 0 to i 5 ft. yards 1 7 bags
from to tt. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN S • ' - Other unsealed and unused well or boring on property? ❑Yes Sip. How many?
O tLICENSED OR REGISTERED CONTRACTOR CERTIFICATION
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This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
Is true to the best of my knowledge.
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Lice see Business ane License or Registration No.
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CertifiedRepres-T----.gnature Certified Rep.No. Date
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MINN.DEPT OF HEALTH COP^f •�t'1'�i' ds�r 011'114)3.
of Person Sean Well or wn
HE-01434-14 ID#53159 5/13R