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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> t. LOCATION OF WE II MINNESOTA UNIQUE WELL N0. <br /> (leave blank If not known) <br /> c°r"`r Name Hennepin <br /> ianfhl► Name Township Number Range Number Section No. Fractten /. MELL DEPTH (completed) Oate sealed <br /> N E � � 01 ti <br /> or Ft. <br /> Orono 117N <br /> or <br /> 23W 7 SW NW SE 194 2/20/91 <br /> Numerical Street Address and City of Well location or Distance from Road S. DRILLING METHOD (if known) <br /> Intersection Ip Cable tool 4E]Reverse 7p Driven 100 Dug <br /> 1360 Vine Place Mound, PIN 55364 2E]Hollow Rod U Air 80 Bored lip <br /> Show enact button or rail 3p Rotary 60 Jetted 9p Power Auger <br /> (IN section grid with 'II') Sketch map of well location <br /> 6. OBSTRUCTIONS <br /> N Well obstructed Q Yes E] No <br /> L - <br /> Obstructions rerored 0 Yes 0 No If obstructions cannot be <br /> i ! removed. contact MOH <br /> W <br /> ' ( - E before sealfng. <br /> T <br /> 1. USE <br /> Xw . . <br /> Is at. 1R]Domestic 4C]Monitoring BE]Neat Loop <br /> 2[] Irrigation SE]Public 9p Industry <br /> 30 Test Well 60 Municipal IC(:]Commercial <br /> ►-I R La 7[]Air Conditioning lip <br /> 1. PROPERTY OWNER'S NATE Milling Address 1f different than B. CASING(S) <br /> property address indicated above 10 Black a0 Threaded 20 <br /> Earl Norwood 20 Ga Iv. SQ Welded <br /> Jp Plastic 6[]Stainless Steel <br /> HARDNESS OF 3 In. to ft. <br /> 1. FORMATION LOG COLOR FORMATION FROM TO <br /> If not known, Indicate formation log from new well or nearby well. In. to ft. <br /> Topsoil Black 0 1 9. SCREEN <br /> K]Screened well from_ ft. to_ ft. <br /> (lr known) <br /> Clay Yell 1 30 p open Hole from_ ft. to_ ft. <br /> Clay Blue 1 30 42 10. STATIC WATER LEVEL <br /> 50 ft. a below p above <br /> Clay/Gravel Blue/ rcwn 42 152 land surface Data Measured 2/20/91 <br /> Clay/Gravel Redd' h Brown 152 194 Il. WELLHEAD COMPLETION <br /> I[] Pltless Adapter 40 Found Surfed <br /> 2E] Basement offset <br /> 30 Well Pit <br /> 16. REMARKS. ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> in"eat Cement 20 Santonite U <br /> Formation log taken from new well drilled Grout material 6 bagsfrom 0 tol94ft. cu. ydj35 <br /> 2/18/91 unique welly 478352 <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> feet direction type <br /> Well disinfected before sealing? [] Yes <br /> r <br /> 11. PUMP ®Removed 0 Not Present <br /> Type: ID Submersible 30 L.S. Turbine SD Reciprocating <br /> 20 Jet` Ap Centrifugal 60 <br /> 16. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells 1n remarks seetlon or an back.) <br /> Other unused well on property1 0 Yes [� Mo <br /> n D Abandoned: p Permanent 0 Temporary 0 Not sealed <br /> t1►` <br /> 11. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was sealed under my Jurisdiction and this report <br /> Is true to the best of my knowledge and belief. <br /> StevensWell +D�trilling 27194 <br /> 62VTI-111g"hwa' "1G West License N0. <br /> Address Maple PAin,, Mel 55359 <br /> Signed Date 2/20/91 <br /> Randy Jo son Date 2/20/91 <br /> FFICIAI ASAIIOONtN WILL RECORD (May be used for Property Transfer) Name of Driller <br /> LAlFMrAaTt IIT1 WrI7 DMW <br />