HomeMy WebLinkAbout1995-04-21 MDH Well & Boring Sealing Record Minnesota Well and
Boring
WELL OR BORING Lo W(E MINNESOTA OE T NT OF HEALTH Sealing No. . H 5 9 230
�
' County Name 'WELL Air VVRI� �ING
RECORD No
mescita Statutes,Chapter 1031 or W1ififfik o_ )
, . `' a T o t#s; ` b. Seclien No, FOCl/001m n. FAR Approximate Date Well
� * IL 20, 1995 or Borng Corstnrcted
1992
r l w
Numerical Street Address or Fire er and t ly atW€S of Boring Location
14493' a 1 t)epth eefore Sealing 137 ft. Original Depth 7 ft
Show exact location otwell orboring Sketch map of well or.. Static Water Levi J
in section grid with"X". location.showing property iii7ii O Approximate
1611 44 4:4*-'1 $4"4114 i
iiiii �
Single Aqutfar 0 Muftiaqurfer 1t 5 ft. V below atxwe land surface
pi I II f c TYPe
1111111111111111 ae1 ; eei ❑Plastic a Tile 0 oftner��� VP.
4 94 104
.. Screen from to ft. Open Hole from 104 lttoo ft.
• OESTRUCTIORIDEBRISMILL
. 0 Obstruction 0 Debris 0 Fill
iggSfit MIL' . (SUM N
az. , _.... . Type of debns/abstruchon .
1749 snuarr Obstruction/Debris/Fill removed?.❑Yes (ft-No
STILLIIRTS2 r 55082 PUMP
0 Removed 0 Not Present 0 Other
CASING
GEOLOGICAL MATERIAL I COLOR 1 S I FROM 1 TO
Diameter
If not iarowno,indicate estimated formation log from nearby well or boring.
Diameter Depth Set in oversize hole? Annular space Madly grouted?
0 94
CLAY/GRAVEL 0 2 in.from to ft. id Yes ❑No fl Yes ❑No 0 Unknown
Lingtocir j rictiLow 140 in.from to ft. ❑Yes 0 No 0 Yes 0 No ❑Unknown
in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown ,
METNO°USED TO SEAL ANNULAR SPACE SEI WEElt3 CASINGS.OR casein AND*ORE t$OLE:
1 No Annular Space Exists
0 Annular space grouted with trentie pipe
a
0 Casing Perforation/Removal
l
in.from to ft. 0 Perforated 0 Removed
. _
in.from to ft. 0 Perforated 0 Removed
AR 2 19115 '
Type of perfolato0
-- - =P. # . 0.0lher
I 111+ annum:MATERIAL
MN State Q ,
a� O 1 . to M State Re Jai o n s G—ting materNF fraj7 jitati ft. 44? bags
from to ft. yards bags
•
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEAUNG
GEOLOGY NINON: raan ORIGINAL 1SX1 from to ft. yards bags
Sala.-T instrzivaiwaaAntrow from to ft. yards bags
10301 PERNSA IX BLVD. , SU1T 1< uNSEAttu ed we AND boring on p p
Other urmealed well or boring on Property? 0 Yes a No
NI 5418, Nil 55305 UCENsED OR REGISTERED CONTRACTOR CERIWICATION
BRIAN cumustiaessos 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.
?1rl15 .
Contractor Name °"- ,. License or Registration No.
4/21/95
Authorized kve Signature Date
LOCAL COPY H Name of Person Sealing Well or Boring
HE-01434-01