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; wELL OR BORING LOCA7lON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 018 3 8 <br /> ;County Name <br /> WELL AND BORING SEALING RECORD Mennle9oNa Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave blank I�not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> -` 8rono 118N 23W 31 ,. �. �. `�\ ��?�' , =� <br /> . f ._�- 1 C� �..� <br /> GPS Latitude degrees minutes seconds - <br /> LOCATION: Depth Before Sealing ft. Original Depth ft. <br /> Longitude degrees minutes seconds qpUIFER(S) STATIC WATER LEVEL <br /> Numericai Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 4385 Ct►ipge�ra Ln, OlOAO WELUBORING Q'Measured ❑Estimated <br /> i� <br /> ❑Water Supply Well ❑Monit.Weil � <br /> Show exact location of well or boring Sketch map of well or boring // ,I��� <br /> in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other �ft. [�below ❑above land surface <br /> n <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ��� �Steel ❑Plastic ❑Tile ❑Other <br /> W -� - -- - -- --�-- E , WELLHEAD COMPLETION <br /> � � <br /> � , , � ����` ` Outside: ❑Well House Inside: ❑ Basement Offset <br /> �-- �-- -;-- --1-- � . ,4 CITY OF ORONO <br /> �m�� i7 Pitess AdaptedUnit ❑Well Pit <br /> ---- -i-- -i-- --�— I 7C� <br /> 1 ❑Well Pit ❑Buried <br /> �l� S �" <br /> im/re��.f il..'�C� ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> .7. Marc Fritzler � D68 1 1.. Peterson oiameter oeptn _ set in oversize no�e? Annular space initially grouted7 <br /> Property owner's mailing address if different than well location address indicated above � <br /> � in.frOm� to� —, ✓ft. ❑Yes [�`�No ❑Yes ❑No �Unknown <br /> 4385 Chippewa Ln <br /> Maple Plain, AII�i 55359 in.ffOm to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> J. Marc Fritzler & Des 1 L. PeCerson ` ,t. �_.� � . � <br /> Well owner's mailing address if ditterent than property owner's address indicated above Screen from .�' �� to ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Y2S ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation Iog from nearby weil or boring PUMP <br /> Type ,�.� �`�}r1 <br /> Removed ❑ Not Present ❑Other <br /> METHOD USED TO SEAL dNNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [�No Annular Space Exists ❑ Annular space grouted with Uemie pipe ❑ Casing Perforetion/Removal <br /> /\ <br /> in:from to ft. ❑ Perforated ❑ Removed <br /> • <br /> in.from to ft. ❑ Perforated ❑ Removed ` <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of b��entonite=50 Ibs.) <br /> �{ t +!i ( � <br /> Grouting Material 'v"���' �� `� ���}��� � �om�to�k' yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIF�CATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Steyen� nrillino & Anvi nnmpn al Sv _ 86�j5l�. <br /> Contractor Business Name License or Registration No. <br /> y�, ;�, g � a�i--U� <br /> Authori�e�d epresentatiJeSlgnature � �� � `"—�--"'"-�-_.._ Date � <br /> �.�!"'� <br /> LOCAL COPY H Z O i V�H � J '� ��t" j`` <br /> Name of Person Sealing Well or Boring <br />