HomeMy WebLinkAbout2004-06-01 MNDH Well & Boring Sealing Record - Well #2 "N A
WEL• OR BORI G LOCATION k _SOTA DEPARTMENT OF HEALTH Minneso .:II and Boring H 212113
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C•uni Name
g WELL AND BORING SEALING RECORD Minnesota Unique Well No. 1
Minnesota Statutes, Chanter 1031 or W- series No.
I, Y (Leave blank't not known)
• - Township No.� Range No Section Ni Fr cti n s) Date Sealed Date ell or B ring Con ucted
i kTI) \ t — 1
GPS • itude degrees minutes seconds 1 - "'°^ ---- - --.._
LOCATION: Depth Before Sealing 1, ., ..:, ni al Depth ft.
Longitude degrees minutes seconds AQUIFER(S) i STAT WATER LEVEL
N merical Street ••-. ress or Fir- Nu •er . d City o 04.- ■ f .ring ocation iii Single Aquifer ultiaquifer
r"J 6 1 1 1 J WELL/BORING Measured ❑ Estimated
�►.oi `N_. _� • A'A.+ Water Supply Well ❑ Monit. Well j
Sho I p .t well or b ri S'etch f b h
'1 I Env. Bore Hole ❑ Other —ft. below ❑ abov , land surface • i • on g . 11 J in In d I t• "11 ` FA
� , ,.. _ ' .� R ` @' �• • SING TYPES) C7
1 \a‘,.)
II teel ❑ Plastic ❑ Tile ❑ Other
r' ELLHEAD COMPLETION
111111111111111 , ,' Outside: ❑ Well House Inside: Basement Offset
1 ! � �. „/ ❑ Pitless Adapter /Unit ❑ Well Pit
1111111111111 _ ^ � `!) ❑Well Pit ❑ Buried
S
lie-.- r mN• 4 11. •4 y`� n) . " , ❑ Buried
i P :,1 TY O nR S NAME /COMPANY - I 4 CASING(S)
r — '4 .1 (, , Iiliiiift. ® _ l ) i Dia a Depth g Set in oversize hole? Annular space initially grouted?
Prop "Wn'' mail; %..ress if•i - - nt th wel4. a address] •icated-above ( v �/
In. from A 1, • t. ❑ Yes to ❑ Yes ❑ No Unknown
.. 4 in. from is' bto t. Xnes ❑❑ ❑ Yes ❑ No Unknown
In. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
WELL OWNER'S NAM ANY NAME l SCREEN /OPEN HOLE t
Well owner's mailing address if different than property owner's address indicated above Screen from to ft. Open Hole from A to 4_6___ ft.
OBSTRUCTIONS
❑ Rods /Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction
Type of Obstructions (Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstr tions removed'? ❑ Yes ❑ No Describe
FORMATION
If not ••wn, indicate estimat . . log from nearby well or boring PUMP I
❑Re moved ❑ Not Present ❑ Other
irJAM S WA 4t I - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
.� ! M. ❑ No An r Space Exists ❑ p r n �ul�ar space grow d •th tr pipe . Casing Perforation/Removal
KSW 1 ' in. from i U to Perforated ❑ Removed
l� _ . : i n from ` to ft. ❑ Perforated ❑ Removed
1
i Type of perforator T
1 T As.
� ri'_ '' /����' J ® ��� i. , ❑ Other =NI had
EO M GROUTING MATER 1 (One bag • cement = 94 I • _., one bag of entonite = 50 lbs.)
1 /lK�'`< s �� ira
1 Material _ .1',fi f Ir r fro • ,...A.... o - yards bags i
t •
�� y ards a
PI r I rl . �' IVA\Z'
I a (�
� � � i _ / , „ , ��, . ' 4. h___r L� � from ; to ft. yards �' t -'/
� ` �4 �M �,1 I , � 0 HER WELLS AND BORINGS ) �` A A LIChatb 4
R M ' • • CE OF i •T D IFF 11 �T ES • • SE ' INh Other unsealed and unused well or boring on property? ■ Yes ❑ No How many? o
,` T 14 .II I J � {�L 4 I 1 I`4,; k 4 (I.• CEN • OR REGISTERED CONTRACTOR CERTIFICATION
� AL .Jl „AI / \ is w . • boring as sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is
.t (� J true to • est of t knowledge.
i P �l S - / 1
L 1 % 4 '- _' i 0 - t .A ;A �. i
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id % G '!, Cont 'or Business Name r ense or Regis rail: r No. 7 ,.. n it
,,p„..... C 9 .,
Authorize. Representative Signature mare
I LOCAL COPY H 212113 L- U'
Name of Person S e aling Weir Bag