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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED MELL RECORD <br /> 1. LOCATiON OF �El� MINNESOTA UNIQUE WELL N0. H81897 <br /> i�eave Dtank tf not known) <br /> c°""`Y """` Henne i n <br /> Tornsnip Mame Townshfp Number Range NumOer Section No. Fraction 4. 4ELL �EPTN (cospleted) Oate sealed <br /> N E 4 k of y <br /> Orono 118N s� 23W w' 29 SE NW SE 86 f`• 3/24/93 ! <br /> , <br /> Numerical Street Addresz and Lity of Nell Location or Distance from Road 5. �RILL(NG METH00 (1f know�) ; <br /> (nursection 1�Cable tool 4�Reverse 7(]DNven 1�Oug <br /> 3405 County Road 6 Long Lake, MN 55356 Ho�,o� aaa � <br /> 2[] SQAtr �Bored 11� � <br /> i <br /> SAow eaact locatton of well <br /> 3�Rotary 6�Jetted 90 Pow�r Auger <br /> � (in sec N on grid rltA 'X') Sketth map of well louttOn <br /> 6. OBSTRUCilONS <br /> � , welt obstructed Q Yes [JC� No <br /> - � - - - - -- -. ODscructtons removed 0 Yes []No If obstructions cannot ee <br /> � � <br /> � removed, contact lIOH I <br /> y - • - - • • -I- . - E Cefore sealing. <br /> : . , T �. �SE <br /> , ' �x ti.�. l�Domestic a0 lbMtoring 80 Neat looD <br /> ; ; _ ; : I 2�lrrigation 50 Public 90 [neustry � <br /> I <br /> ' ' 1 30 Test Mell 6�Municipal if�Comaercial I <br /> � �--1 SL---r ]QAir Gondltianing 11(] I <br /> 2. PRUPERTY ONNER'S NAME Mailtng Address if dlfferent than 8. CAS[N6(S) I <br /> � property address indicateE above 1[�Black CQ Threaded 7[] 1 <br /> � i <br /> 2[J Galv. 5[]Yelded � <br /> Charl otte Forsythe J[]Plastic 6�Statnless Steel <br /> � <br /> NARDNESS OF (} I <br /> l. FORMATION lOG COLOk FONMIlTION FROM TO 1n. to ft. <br /> if not known, indfcate forma[fon tog from new well or nearby well. in. to /t. � <br /> TO S 0 1� �d C IC Q 2 9• SCREEN , <br /> �Screened vNl l tros ft. to ft. � <br /> e 1 1 0 2 2 5 ❑ODen Hole from ft. to ft, (<� known) � <br /> — — , <br /> C�a,Y �u e� ray 2 5 8� 10. STATIC WATER LEYEL � <br /> Gravel & sand ul ti 80 g6 �� f`• � De1oy ❑'°°"' 3 24 93 <br /> lend surface Oate Meesured � � <br /> 11. WELLNEAD COMPLETION � <br /> 1�]Pttless Adaptar �Founa Buried � <br /> 2[]Basement offset '� � <br /> 30 Well Pit � <br /> 16. REMARKS, ELE4ATION, SOURCE OF OATA - CASIN6S REMOVED, CASIHGS PERFORATED, ETC. <br /> 12. GROUTING INFONlNTION i <br /> � 1�Neat Cement �Bentonit� � i <br /> IFormation log taken from new wel l dril led Grout material 7 baqs ,rom 0 �,86 ft. ��. ,as� <br /> I 10/5/92 - unique well #480299 _ _ ; <br /> ---� <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> _ feet directlon �ype <br /> Well dlsinfect�d befon sealingt � Yes <br /> 14. PUM� �Remnved �Not Prasent ! <br /> Type: l� Submtrslbte �L.S. TurOine �Reciprocating ; <br /> 2[J Jet �Centrtfug�l 6� I <br /> � <br /> 15. ElIISTING MELLS (Ple�s� sk�tcA loe�ttons at abanConed and � <br /> activ� walls tn rewrks sectton or on oack.) I <br /> Othar unused w�ll(s) on prop�rtyT �Yes �No <br /> Abandoned: []Perm�nent �Temporary �Not sealed I <br /> 17. NATER HELL CONTRACTORS CERTIFICATION <br /> This Nell was sealed under my jurisdtction ana this repor[ I <br /> is true to the best of my knowledge and beltef. <br /> Stevens Well Drilling Co. 27194 <br /> "�C�6��0��11sig�iwav 12 We`s,�`�z` N°. � <br /> Aaa�e�s Ma 1 e Pla 'n MN 55359 � <br /> sty�ea i .c �,,. . �-�._. o.ce 3 30 93 <br /> ��ul Swearingen n,t. 3 30 93 <br /> ifIC1AL ABANppNEO YEIL RECORO (lf�y b� used for iroDerty Transier) Nane o1 Dr111�� <br /> IMPCRTA9ls �ZLB IIIITH Ddgp <br />