HomeMy WebLinkAbout505 Hope Dr - Well and Boring Sealing RecordU - (V)1( </,= n L1
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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring
Sealing No.
WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes, chapter 103/ or W -series No.
P (Lame dank it nod known)
H
422361
WELL OR BORING LOCATION
C04 N,�rne`/
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Town hip Name
Township N
Ran a Na
Section No.
Fraction (sm... ig-)
Date Sealed t
Date W 11 �or/Bonn, jConstructteed�j%
degrees (to four decimal pla- so ���_
GPS LOCAT G decimal���_Longitude
Latitude_ �� +�
Depth at Time of Sealing___Sealing---2--4-------ff.ft.
UIFER(S)
Single Aquifer ❑ Multiaquifer
(a
Original Depth ft.
S TIC WATER LEVEL
,,(/�
Measured Date Measured ( — �'"- - E:1 Estimated
` ft. below ❑ above land surface
_ ._._
Numr�eric^al Street Address or Fire Number and City of Well or Boring Location
5 +�/ t�j jt;
�j(�
WELL/BORING
❑ Water -Supply Well ❑ Env. Well
A Temp. Boring ❑Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X' location, showing property
N lines, roads, and buildings.
--'--- -- `-- -- `-- ---'--
j
------ --a-- ---� -- --'
CASING TYPE(S)
1 U'V`i 7 4666&
�[
❑Steel ❑Plastic ❑Tile �; Other
,
WELLHEAD COMPLETION
W E
�___ __ ;- _ ___� __ __ r__
T
MileWell
--.-'----�-t-Pit
S
id/[]BOffset
Outside: Adapter/unit ❑ ns ent se
O : ❑ PAt Grade 1
Pit rl Ho se---
❑ Other_
❑ Buried
�----1 Mile{
❑ Other
For temporary borings, provide additional location
information, a site sketch, and geology on a separate page.11-7
CASING(S)
ole? Annular spac initially grouted?
Det�j, Set in ovKN,
in. from to J� ft. ❑ Yes ❑ Yes No ❑ Unknown
jn. ,ro _ (( ft. i] Yes ❑ No ❑ Yes ❑ ❑ Unknown
.�...,r^
_ in, from_ to _ ft. ❑Yes [jNo ❑Yes [-jNo Unknown
PROPEFyFY f R'S NA /CO N , $t
Pr erryfoVoer/s�m iiing ad� rje,7s�� °if differenF h)UVanwell location address indicated above
j 4 Pi LOT 6)
���� ! M � 5 � ( � �
SCREEWOPEN HO
Screen fr to ft. Open o ro'000 to
J111
WELL OWNER'S N� ME/COMFANY f AME
+
OBSTRUCTIONS
❑ Rods/DropPipe ❑ Check Valve(s) ❑ Debris ❑ Fill Obstruction
Well owner's mailing address if different than property owner's address indicated above
t
Type of Obstructions (Describe)
t.
Obstructions removed? ❑ Yes ❑ No Describe
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR FROM TO
Present ❑ Present, Removed Prior to 5ealin �—"FORMATIONg ❑OtherIf
�kp,p_
not known, indicate estimated formation log from nearby well or boring.
MET D USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASIN AND BOREHOLE
o Annuls Exists ❑ Annular Space Grouted with Tremie Pi ❑ Casing Perforation/Rem
a g Di eter
in from to ft. Perforated Removed
A� L {U
_ in. from ft. ❑ Perfora ed ❑ Removed
Type of Perforator
VARIANCE "'""'r►
Was a variance granted from the MDH for this well? ❑ Yes No TN#
GROUTING MATERIAL(S) +`\
Grouting Material EM= 0 to7-A ft. yard3 bags
from to ft. yards bags
_ from to . ft. yards_ bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes go How many? --�'
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules, Cha er 4725. The information contained in this report
is true to the best of my knowledge.
REMARKS, SOU CE OF ATA, DIFFICULTIES IN SEALING
�-� � ��� ���� �
M. !;/ 1 l v N A j
Licensee Bu ' es ame License or Registration No.
(•��j�/
Cerkh*Vres;Vhativ�eV& nature Certified Rep. No. Date �—
LTXV KWC
-
Name o Person Sealing Well or Boring'
INAPORTANT-FILE WITH PROPERTYI
PAPirRS-WELL OWNER COPY
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