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HomeMy WebLinkAbout2004-07-07 Well & Boring Sealing RecordWELL 01 SORIJ LOCATION MI. JOTA DEPARTMENT OF HEALTH Minnesol .and Boring ng No. WELL AND BORING SEALING RECORD MinSeanesota Unique Well No. I'„I 21212 Coun N me e Minnesota Statutes, Chapter 1031 or W. -series moo. 1. Jns N e Township N Range No. Section o. Fra 'on (s ) Date Sealetl Date Well or Sort o trudetl GPS Latitude degreesminutes _seconds LOCATION: s Depth Before Sealing It Original Depth Longitude degrees _minutes _seconds O IFER(S) Single Aquifer ❑ Mu iaquifer STATIC WATER LEVEL Numeri sl Street Add re s or Fire umber a d City W Il or ori Location - 1 L E ORING Measured ❑ Estimated Water SupplyWell ❑ Monit. Well exa to :oi ell r b g map r as i A g y n Env. Bore Hole ❑Other fl.below ❑ yndsu , e CASING TYPE(S) J Steel ❑ Plastic ❑ Tile ❑ Other WELLHEAD COMPLETION W -- - - - -- -- — E � n ubilde: ❑ Well House Inside: ❑ Basement Ottset 1 ❑ Pulses AtlapterlUnit Well Pit S � A Welt ❑ Well Pit ❑ Buri f. C] Buried PR PETY NE 'S A PA Y A E CASING(S) Da m to epth Set in over. ole? Annular space initially grouted? Prope v is mai mg a ss -Brent ih c Ion ress Iodi ve ///�yyj��� ,,�,, qqq rr��� �7LT[.J!/ �y in. fo it. ❑Ves )(No ❑Yes ❑ No Unknown /❑ in. from t0 ft. ❑ Yes No ❑ Yes ❑ No ❑ Unknown _ in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown WELL OWNER'S NAME: N NAME SCREEN/OPEN HOLE Screen from to R. Open Hole from 10 V L Qu. Well owner's mailing adtlress ent than pe y owner's address indicated above OBSTRUCTIONS ` ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill R�' No Obstruction T Type of Obstructions (Describe) Obslructl remoV ? ❑ Yes ❑ No Describe GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO If not known, indicate estimated formation log from nearby well or boringhis PUMP Os Type I IM, IK Removed ❑ Not Present ❑ Other e" M 00 USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in. from to ft. ❑ Perforated ❑ Removed in. from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATE AL(S)O' (One ba ps., one ba of bentonite= 50lbs.) Grouting Material it _ a �yy�saa,rrr'ds from to ft. yaltls�© loom to It yards a OTHER WELLS AND BORING . ��`(��`' ` Other unsealed and unused well or d on op rtyes LJ No How many? bF DAT DIFFICU I S IN SEALING I LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This w or burin was sealed in accordance with Minneso Rules, Chapter 4725. The information containetl in this report is Vue t t best o y knowledge. 1 NRSOUR lit J Cro'�//actor Bus/ine�ss Name ense�(o-/ryRegrsf�tio%n (} (� M Authonzed Represen(aNve Signature Data Z V 4: 1; LJ LOCAL COPY 1 H 212120 Name of Person Sealing Well or Boring I 11 J M