HomeMy WebLinkAbout2006-05-23 Well & Boring Sealing Records1 jri 1 —1r11K_jKs0 l c . D,'j iYIUH WILL l`llaM I I 1 UN 651 201 4599 P-02
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WELL aA #NG LOCATION ki-I 1 rj9CQ TA DEPARTMENT OF HEALTH Ntlnrx�, i 11 and Baring H 2 40948
County Na me �" 'WELL -AID BORING SEALING RECORD Sealing Mt to
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Minrrosow Statutes, Cnaptcr YOW o r 1�1- 4erio� No.
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LOCATION:
t7e� More 81�kiina .�. - _....�. �
LongKudn depmes minuted STA'x'I;G WAYI!K LEVEL
Numerlcu# Street Addrosa of f9ra N u mt) 9 r grid City of Nell or BQfin I40rAr;rn ❑ Mullitiquifrr
1 35; 1 31
.�,� ti, Vp4 R1 MG � f�[ur��u ►ao ❑ [;.r5t[�1e� t�:r�
Water Supply W011 ❑ M OM, Well
Show exact t4walion of wall cr bong Sk9tch rnjp of well ar borinq ❑ P-MV, Bore Hok ❑ bider �, il, � Wow ❑ ObOV0 Iano cuflace
in section g6d WAh 'X ' Rf10W #1'3 prowrti
linos. tAtidS, t7r►�i (t►ll ilk G"NG TYPE(S)
{ if StavJ ❑ Plaek ❑ TggT ❑ blhef
- -; . . ►. - - - .. WELL.HEAD CDMPLET ON
vv
+ Oufsid,e: ❑ WON HOM fntAde: ❑ M)"rowit Offset
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nV10 p Pidnx: A48pier /Un" well Pit
1F1rBli P`lt ❑ f311 Fic:t
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P 'Y OWNER'S NA#�+ E OMPIANY NAME CAS[;fit�}
Dapm 'Sox in overs."Zo hale? Annular space ir>f al )y groultia7
P gp" vurncr`r. mailing €iddo YtglftQmrn than wet! k=tW adar4 >x need ubDve Ifl, f rom to ft,
❑ Yea ❑ No ❑ YES& ❑ No * Unknown
A� 1 In, from #o �. ❑ Yee C) No ❑ Yet ❑ No ❑ un"Wn
in. from to T f ❑ Yos D Na C7 Yos ED Na ❑ VRKnowri
V1la 657Nt.K3 NA101000MPANY NA1►+tL � BC"Ej:NIDPEN HOLE
Wel# $rr " from to ?t, o pen Hole furl �, a..., ,. to
���YAUGTIO
• ❑ Rods/Drop Np�a Q Check Vahne(s) Q Debris ❑ Fttt No Obs nxton
, • 'ape of Obstructlone (Doecribe)
GEOLOGICAL MATt RrAL COLOR HARDNESS OR Mom TO Obstructio FCmoved? ED Yes C.1 No Describe ._._
If not knowN k+cirzoto ❑NI1111,310d �rmat 01 t
PUMP
...�... y C� ffarn n�arCry w�li or �[]ri�1� .. •.,.,..,
Typo
_... , .. I& Removed D Nei Prar.,�nt 0
_. M "4011) k SW TD SCA ANNLJLAR SPACE SET'W"N 2 CASINGS OR OA$ING AND BORE HOL131
a nt 'Nkr Annufal fta Exist L1 Ai)t)Uar scac6 g roklr:d with I mmix poo ❑ Cuwng parroratiorts�mvva
�"" _r ire. Irani tv ,M ffi. ❑ Pe rf o rated ❑ Rty`movr.
�.� +w •�_ In. fro r i .rs t o .. s.aa, -- ❑ I erfo at®cl ❑ RCMGvPd
Typo of porforator
❑ Other ....,.... „.,_ �. ..
GROUTING MATIaR(AL(S) (One bag of cemanl = 1bs., on bug of toe ntonItc 50 thy)
C �rpri�l
et4 fmfrt� it. Y,.Xrdtt Daps
..•, a•,,� frol to .,... .- fl. - yard:, t>aw
.. .....,�..,.._ from 1 10 ....... ft, .............___.... yar& .. ... baos
REMARKS, gounce pE DATA, DIFFICLIt.rics 1 AA,�Owo e6,?N>
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LICENSED OR RMS`TERED CQi4 CwR CERTIFicArioN
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FACSIMILE COVER SHEET
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05/25/2005 14:07 FAX 912 395 7131 CSM CORPORATION
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DEVELOPING REAL ESTATE FOR P '90PLE,
BUSINESS & COMMUNITIES
500 Washington Avenue South
Suite 3000
Minneapolis, MN 55415
'hone 61 2-395-7000
F TRANSMITTAL
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Fax Number. Cpl / 4a9 -
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05/25/2006 14007 FAX 612 395 7131 CSM CORPORATION
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WALL DRILLING AND PUMP REPAIRING
20335 FOREST $OULEVARC) NORTH (HIGHWAY 61)
FOREST LAKE, MINNESOTA 55025
Office Phone (65 464 -3939 e ( 7 386 -3992 * (T1 5) 48,x-39:39
Fax (65 464 -85
Z002/007
D a t e : - on
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From:
McCullough & Sons Inc
OF PAGES INCLUDING THIS COVER SHEET:
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IF YOU DO NOT RECLINE ALL PAGES OF HAVE DiFFICUL'T REACHING THIS DOCUMENT PL°`A• P.
Mr('U'I..L0UGH & SONS, T.qC , AT (!651 4 6Q - 93 � THANX YOU
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WE SFA �IG 140TF#Ck71 )i4- WEt..L SEALM NOTIFIdATIbM 15 VAUD FOR 16 MONM S wwaam Urkiia wa t<4o. or W4ar%6 no,
SOM n *Kptttion "end p ont (�r.k, �y order, or croo card intatmatlort) to. (L"" � � Alm �� �firv�aa� vr�rlt MW �� ttee�lna H46
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05/25/2096 14a08 FAX 612 395 7131 CSM CORPORATION
�.N:% gONS well drillin g-
WELL DRILLING AND PUMP REPAIRING
20335 FOREST BOULEVARD NORTH (HIGHWAY 61)
FOREST LAKE, MINNESOTA 55025
OffiCe pflone (551) 464 -3939 4 (715) 386 -3992 & (715) 483 -3939
Fax (651 464 - 8349
OF PAG&S r INCLUDING THIS COVER SKEET
URGENT
FOR REVIEW PLEASE COMENT PLEASE REPLY
IF YOU Do NOT RECEIVE ALL PAQES OF HAVE DI FFICULT READING TlilS DocumENT PLEASE
McCULLOUGH 5 SO NS, INC AT (651)464-3 'HANK YOU
2005/007
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05/25/2006 14:09 FAX 612 395 7131
CS31 CORPORATION 006/007
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H 240948,—
rom YEA of 1th, MU s*c"n PC. Box "M St. Pul, a fmacCo %10-075
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