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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> It. LOCATION OP til ll l MINNESOTA UNIQUE WELL NO. <br /> (leer. blank If not known) <br /> County Neee Hennepin <br /> Tiwioip lam' Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> N E b b of ti <br /> or ft. <br /> Orono 118N sr 23W w 31 SW NE NW 127 _5/10191 <br /> Numerical Street Address and City of Well location or Distance fro. Road S. DRILLING METHOD (If known) <br /> Intersection 10 Cable tool a[(N 70 Driven IC0 Dug <br /> 20 Hollow Noe SO Alr HD Bore 110 <br /> 4545 Watertown Road <br /> x]Rotary 60 Jetted 90 Power Auger <br /> Show exact location of well <br /> (in section grid with '11 Sketch map of well location 6. ORSiNUCt10N5 <br /> N Well obstructed[] Yet [ No <br /> Obstructions removed 0 Yes 0 No If obstructions cannot be <br /> removed. contact MON <br /> s before sealing. <br /> W - • - ' - - • -I- E <br /> T 7. USE <br /> 1W Domestic {]Monitoring 80 Neat Loop <br /> • <br /> y .i. <br /> 10 Irrigation S(]Public 9Q Industry <br /> I[]Test Well Municipal 11x]Co.vnerclai <br /> 70 Air Conditioning 110 <br /> ►-1 �i V <br /> 7. PROPERTY OWNER'S NAME Mailing Address If different than N. CASINGIS) ^I <br /> property address indicated above ID Black 40 Threaded 1[] <br /> Earl Freeman P.O. Box 685 7[} Gale. sp Welded <br /> Lemont , IL 60439 7(]Plastic 60 Stainless Steel <br /> HARDNESS OF 2 tn. to ft. <br /> 1. FONMTION LOG COLOR FORMATION FROM TO ^ <br /> If not known, indicate formation log from new will or nearby well. in. to ft. <br /> 9. SCREEN <br /> lc]Screened well from ft. to ft. <br /> (If known) <br /> 0 Open Hol. from_ ft. to _ ft. <br /> 10. STATIC WATER LEVEL <br /> 85 ft. Cg below ❑above 5/10/91 <br /> land surface Dat. Measured <br /> II. WELLHEAD COMPLETION <br /> IC]Pities' Adapter Q Found buried <br /> AC] Basement offset sQ <br /> 734 Well Pit <br /> IS. REAINRS, ELEVATION. SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> Y:Neat Cement 7[]bentonite x] <br /> Grout material3 hags from() to 12-ht. cu. yds.10 <br /> 13. NEAREST SOURCES Of CONTAMINATION <br /> _ feet direction type <br /> Well disinfected before ruling? 0 Yes <br /> le. PUMP 0 Removed c4 Not Present <br /> Type: 10 Submersible x] L.S. Turbine (]Reciprocating <br /> 70 Jet 4E]Centrifugal Ix] <br /> IS. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells In remarks taction or On back.) <br /> Other unused well(s) on property? O Yes Cg No <br /> Abandoned: 0 Permanent C]Temporary (3 Not Sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well wet sealed under my Jurisdiction and this report <br /> Is true to the best of my knowledge and belle!. <br /> Stevens Well Drilling Cn_ :'7194 <br /> ten tee Iwlnuf Na12me license No. <br /> 624 IIighway West <br /> Address Maple P • MN 55359 <br /> sired-jr /Jct.._.. oao5/10/91 <br /> Dias evens Date5/10/91 <br /> Name .f Driller <br /> .f►sort A/AlioONEo wit RECORD ins? M used for Property Transfer) <br /> TXPOtTAI', Pill VITT DRRD <br />