HomeMy WebLinkAbout4772 Heine Strasse - Well and Boring Sealing Recordno L4 q c�cj Ll
WELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSeal
WELL AND BORING SEALING RECORD Minnesota Well No.
Minnesota Statutes, chapter 103! or W -series No.
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Cou�VA�TA
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(Leave Wank if not known)
Tow hip Name Tt nship o. Range No. Section No. Fraction (sm. . Ig.)
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Date Sealed
-�l�Ad 13 ���
Date Well or Boring Con ucted —�
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GPS LOCAT ON - decimal cipgrees (to four decimal plac
Latitude s "- Longitude -06
Depth at Time of Sealing— 7 - __ft.
A IFER(S)
1
Original Depth ft.
STATIC WATER LEVEL
Numerical Street Address o� Number and City of Well or Boring Location
4717 H & E 5r
Single Aquifer ❑ Multiaquifer
Measup�cy dfo Mea ;e _ ❑ Estimated
- ft. ❑ below ❑ above land surface
W L water -Supply
❑ Water -Supply Well El Env. Well 10
Temp. Boring ❑ Other
Show exact location of well or boring Sketch map of well or boring
in section grid with "X:' location, showing property
lines, roads, and buildings.
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CASINGTVPE(S)
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❑ Steel ❑ Plastic [jTile Other_
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ELLHEAD COMPLETION
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Outside: ❑ P ter/Unit ❑ At Grade Inside: ❑ Basement Offset
W ll H
well Pit ❑ Buried NIA:
it
s
F-- t Mile —-{
❑ Other'uried
❑ Other_
For temporary borings, provide additional location
CASING(S)
information, a site sketch, and geology on a separate page.
Dia ter �— Dept" (� Sat in ov iz ole? Annular space 'nitially grouted?
- in. from to L,r (I _ ft. ❑Yes No _
❑Yes No ❑Unknown
PROPER JY OWNER'S ME/CQ,pQP Y NAME
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Property owner mai!ing address if differen Than well location address indicated above
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in. from to ft. ❑Yes ❑ NO ❑Yes ❑ o ❑ Unknown
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in. from to ft. ❑ Yes ❑ No [IYes ❑ No ElUnknown
SCE
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Sc r n from ft.
WELL OWNER'S NAME/COMPANY NAME -
11,1
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill o Obstruction.
Well owner's mailing address if different than property owner's address indicated above
Type of Obstructions (Describe)_
Obstructions removed? ❑ Yes ❑ No Describe
_
PU
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
of Present ❑ Present, Remove P r to Sealing ❑ Other
Type__
If not known, indicate estimated formation log from nearby well or boring.
D Iq I
MET OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE
No Annular Space Exists ❑ Annular S ace Grouted with Tremie Pipe ❑ Casing Perforation/Removal
Q r p ! p p'' t' C S
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Ley 9�WW 7 1
ingDia
n.tr ft. ❑ Perfo ted ❑ Dyed
n. from to_ ❑ Perforat ❑ Removed
Type of Perforator_
¢ C v
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes
GROUTING MATERIAL(S)
Grouting Mate ��from to-* ft. yards bags
to ft. yards__bags
from to__ ft._ _ yards bags
OTHER WELLS AND BORINGS
Other unsealed and unused well or boring on property? ❑ Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Mules, Chapter 4725. The information contained in this report
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
is true to the best of my knowledge.
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/�/` License r Registration1
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ignnattuuurre CeMfie ep. No.
ifdPORTAN-f-FILE WITH PROPERTY
PAPERS -WELL OMER COPY
H 422 360
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Name of Person Sealing Well or Boring
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