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SIATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION V WELL CORRECTED COPY MINNESOTA UMYEII NO. C <br /> (have blank IfF not know.) l.._ <br /> county Name Herne in <br /> Township Name Township Number Range Number Section No. Fraction a. WELL DEPTH (completed) ate sesled <br /> N E � Is at <br /> � <br /> Orono 118N s' 23W M� 32 SE SE SE 98 ft' 06/17/91 <br /> Numerical Street Address and City of Well Location or Distance from Road S. DRILLING METHOD (if kmern) <br /> Intersection 10 Cable tool 40 Reverse 70 Brim 14[3 Bug <br /> 3220 Watertown Road Long Lake, MN 55356 CiHall"'ad i 3 Alr 10 arm IG <br /> >D Rotary 93 Jetted 9Q power Auger <br /> Show exact location of well <br /> (in sect$** Grid with •1') Sketch map of well location 6. OBSTRUCTIONS <br /> N Well obstructed 0 vis ® No <br /> _ Obstructions removed 0 yes 0 a if obstructions 96*mot be <br /> removed. COW$ No <br /> T 7. USE <br /> _ y w. in Domestic 6E3 N6mlto►ial 4(3 Most Lm <br /> - . 20 Irrigation 10 POMC 10 Industry <br /> �. . ..... _.,.. .. I Well est[] <br /> 3 <br /> 1 T ED Mwlctpel 1f0 CoonsRrt1B1 <br /> 70 Alr Cendltionlp 11(3 <br /> 2. PROPERTY OWNER'S NAME Mailing Address If different than 8. CASiNGIS) <br /> property address indicated above 10 Black 43 Throaded 7C3 <br /> Carol Senn 940 South Brown Road 43 Gsly. 113 welded <br /> Wayzata, MLS 55391 40 Plastic 613 stainless steel <br /> MADNESS OF 3 in. to ft. <br /> I. FORMATION LOG COLOR FORMATION FROM TO <br /> If not known. Indicate formation log from new well or nearby well. In. to ft. <br /> 9. SCREEN <br /> E,]screened well from ft. to�. ft. <br /> Pit town) <br /> ❑Open Mole from_ft. to ft. <br /> 10. STATIC WA R LEVEL <br /> 6 ft-99 below Q avow ' 06/17/91 <br /> land surface Date Measured <br /> ll. WELLHEAD COMPLETION <br /> 10 Pitless Adapter Q Fou" Buried <br /> 20 Resonant offset 10 <br /> 10 Vel l pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. <br /> 12. GROUTING IMFORIATION <br /> House has been sold. 1®Neat cement 10 Bentonite 10 <br /> Grout material 4 bags free 0 tog 8 Ft. eu. yds <br /> P.I.D. 32-118-23 44 0013 <br /> 17. NEAREST SOURCES Of CONTAMINATION <br /> _ feet direction type <br /> Well disinfected before angling? C3 Yes <br /> U. PUMP ®Removed ❑Not Present <br /> Type: ID Submersible 30 L.S. Turbine SD Reciprocating <br /> 20 Jet 40 Centrifugal 6Q <br /> IS. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells to remarks section or on back.) <br /> Other unused welI(a) on property? 0 Tea Mao <br /> Abandoned: 0 Permanent 0 Temporary 0 Not sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was angled under my Jurisdictlam and this report <br /> Is true to the best of my knowledge and belief, <br /> Stevens Well DrilliM 27194 <br /> Licensee Business Now License No. <br /> 6240 Highway 1� West <br /> Adareaa le MN 55359 <br /> signal as <br /> 06/18/91 <br /> Tan Stevens ate <br /> FICIAL AWIOONED WELL RECORD (May be used for Property Transfer) Name of Orlller <br /> LIFaNUM8 OPSAR Bass AM <br />