HomeMy WebLinkAboutOak Lawn Resort_35000990379000_Memos,Correspondences, File Notes_Minnesota Well and Boring
Sealing No.
Minnesota Unique Well No.
or W-series No.
(Lsave blank H not known)
MINNESOTA DEPARTMENT OF HEALTH HWELL OR BORING LOCATION WELL AND BORING SEALING RECORDCounty Name
Minnesota Statutes, Chapter 1031
Township Name Township No.Range No.Section No.Fraction (sm ig)Date Sealed Date Well or Boring Constructed
A^At/. 0i»/
Latitude______degrees______minutes_______secor>dsGPS
Depth Before Sealing .ft.Origir>al DepthLOCATION:
Longitude..degrees minutes______seconds AQUIFER(S)
G Single Aquifer G Multiaquifer
STATIC WATER LEVEL
Numerical Street Address or Fire Nurrrber and City of Well or Boring Location
Show exaci loca^ of well or boring ^ Sket^Tmap of well or boring
in section grid with “X” J j .k \ location, showing property
^ ' Hnes, roads, and buildings.^ <i.<y
G Measured ^ EstimatedWELUBORING
Water Supply Well G Monit. Wen
G Env. Bore Hole □ Other____2 ft. ^ below G above land surface
CASING TYPE(S)
-fi-■"i......i—
^ Steel G Plastic □ Tile □ Other,\RECEIVEDt t t t WELLHEAD COMPLETION
Outside: G WeA House
Pitless Adapter/Unit
G Wen Pit
EW
T Inside: □ Basement Offset....i-NOV 1 4 2006
LAND & RESOURCE
□ Well Pit1....1-
n BuriedSKl/nW
n Buried
PROF^mj^CT^R’S^^ E/COMPANYN^ -CASING(S)
Diameter Depth
^ to ^^ ft.Set in oversize hole?Annular space initially grouted?
□ Yes □ No □ Unknown%Property owner’s mailing address if different than well location address indicated above in. from.□ Yes G No
in. from.ft.to □ Yes □ No □ Yes □ No □ Unknown
In. from to □ Yes □ No □ Yes □ No □ Unknown
WELLOWNER'S^Mip^M^NY^ME ^
Weil owner's mailing address if differenHRan property owner^ddress indrateci
SCREEN/OPEN HOLE
Screen from to ft. Open Hole from toabove
OBSTRUCTIONS
□ Rods/Drop Pipe □ Check Valve(s) □ Debris □ Fill ^ No Obstruction
Type of Obstructions (Describe)_________________________________________________
HARDNESS OR FORMATION Obstructiorts removed? □ Yes □ No DescribeGEOLOGICAL MATERIAL COLOR FROM TO
PUMP
If r>ot Imown, irxlicate estimated formation log from nearby well or boring
5^3 Type
Removed2 □ Not Present □ Other.
r'
..
12 Az METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
□ Annular space grouted with tremie pipe □ Casing Perforation/Removal
□ Perforated □ Removed
^ No Annular space Exists
in. from to5^ c "i iu □ Perforated □ Removedin. from to
Type of perforator
□ Other.
GROUTING MATERtAUjS (One bag of cement = 94 lbs., one bag of bentonite = 50 lbs.)
Groutir>g Material from.to yards bags
from.to yards bags
from.yards bagsto
OTHER WELLS AND BORINGS
REMARKS, SOURCE OF DATA. DIFRCULTIES IN SEALING Other unsealed and unused well or boring on property? G Yes ^
LICENSED OR REGISTERED CONTRACTOR CERTIRCATION
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.
No How many?.
extractor Business Name
A A AA j/O^ ^ ry
Person Sealing Well or Boring jT
/’V t/i I Jl yr?r/fref/onNo.
yA/ j/ j/. J t> (j
i*
4 r'
License or Regis
AutPforizedRepresenta Date
H 250932LCX>LCOPY