HomeMy WebLinkAbout2004-05-28 MNDH Well & Boring Sealing Record - Well #1 k SOTA DEPARTMENT OF HEALTH e H 212112
c ,iII and Boring
WELL OR BO 'INC LOCATION
C Sealing
unt Name j WELL AND BORING SEALING RECORD g No
r
1. Minnesota Unique Well No.
Minnesota Statutes, Chapter 1031 or W- series No.
, J t . 1 , � 414 ies (Leave It
- To ns �Na a To ship ,. Range No Section No. Fraction ( # y�) Date Sealed Da Well o Boring C) structed
GPS L t de degrees minutes seconds
LOCATION: Depth Before Sealing ' ft. Original Depth ft.
1 Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL
I Nu eri .1 treet Address or Fir- Nu • .er +nd City L ; II or. 3ori g Location ❑ Single Aquifer XMuitiaquifer
i ' WELL/BORING )(Measured ❑ Estimated
. . � 1 f 4 I" r ater Supply Well ❑ Monit. Well /� �
`� • tlon of well r boring • Sket II 'T �' r .,. f �f
Oft � i lo- w rt. ?c\I nv. Bore Hole ❑Other `���J' 't. apelow ❑above land surface Iffy • 11111111 • +��` f • -N '� '' •SING TYPES) �t
r A � 1� Steel ❑Plastic ❑Tile ❑Other
W 1111011111 '
E ) -
/� \ WE COMPLETION
1111111111111111 I Outside: ���� H Inside: ❑ Basement Offset
• \,( j ' 4 6 itless Adapter /Unit ❑ Well Pit
EM�� 1 1 _ ❑ Well Pit ❑ Buried
I /MN 4 t • ' El Buried
• • RTY O S 7 D t • • ► - ` CASING(S)
i, � Ma,�, _ 4' 51?
Diar t s -pth p r t1 Set in oversize hole? Annular space initially grouted?
Pr..erty o - ms's mailing address `di • ent t n Will .c. • addre l l ed a ove L�! : ` \\ �`
�^ / r in. from ` . - +� **ft: es ❑ No ❑ Yes ❑ No Unknown
in. fro to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
WELL OWNER'S NAME /COMPA n i.. 1„, f I r /A s SCREEN /OPEN HOLE 4
Well owners mailing address if differen 1h. • •.erty owwne's address indicated above Screen from to ft. Open Hole from�_ t0 OBSTRUCTIONS ��,�
❑ Rods /Drop Pipe 111 Check Valve(s) ❑ Debris ❑ Fill o Obstruction
Type of Obstructions (Describe)
'LOGICAL MATERIAL i COLOR HARDNESS OR FROM TO Obstructio c i emoved ❑ Yes ❑ No Describe
FORMATION
PUMP
r n, indb .te esti ated fo IL log from neat well . baring M 1
� Type �1,. _ :• 1 � • ` _
�� • ❑ Removed Lot Present ❑ Other
1'? METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING A BORE HOLE:
O `, ' ! '• +� ❑ No A n ul Space Exists Annular ace grouted w tremie pipe Lasing Perforation /Removal
�1� _ XPerforated iM . _ _ . ri ‘ in. from �to ft. ❑ Removed
` \1 in. from to ❑ Perforated ❑ Removed
® Type of perforator -- ,1'Y C _ . ,
tial �D, . ❑ Other
' \ GROUTING MAT: - AL(S) (One bag • cement = 94 lbs., one bag of bentonite = 50 lbs.)
IN
F_ : ���_ �
�5. 111' ' ° G ro _ ateriel f _ ' r rom - _ f - o yards b ags
�- 44 1� r ® ' ;
il r ��� } 4 . �= m i -' 1_6 ft. yards t1'nt
i - - El from � to ft. yards T'' �"I��
a OTHER WELLS AND BORINGS .� `t ! it ;. "* f U O i
RE ∎ARK- S• U RCE OF DATA, DI , ICULTIES IN • ACING 1 - * / , S
` ` A \ Ot unsealed and unused well or rl ape ? ❑ Yes ❑ No Ho w man
R ` }� y 0 %. , $ .i! ICENSED OR REGISTERED CONTRACTOR CERTIFICATION
/L � � 111, V•• is 1 - h I or bore • was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is
p . � _ true I. e best , y knowledge. ! A.
*,.� `Y 1 Iii 1 �� /1
4 4 11_ , r L �„-, � ; . Contractor Business Name Lice ' o r'eg ation No.
�� 11-
Authorized Representative Signature >
l..00AL COP`: H 212 112 /A. �_ C7 7.1 J L ,. le i }�
Name of Person Sealing Well or Boring