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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO. <br /> (leave blank If not known) <br /> County Name HENNEP I N <br /> - <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> MOUND 117N or 23W or 6 5'i kSW of SW 70' ft. 02/02/92 <br /> S W <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) <br /> Intersection 14 Cable tool 40 Reverse 70 Driven 1C{]Dug <br /> 4760 WEST BRANCH ROAD, MOUND, MN 55364 20 Hollow Rod 50 Air BQ Bored 110 <br /> 30 Rotary 60 Jetted 90 Power Auger <br /> Show exact location of well <br /> (in section grid with 'X') Sketch map of well location <br /> N '`' I\ r`(‘-,,(‘-,,,,,V-'r6. OBSTRUCTIONS <br /> W�n Well obstructed 0 Yes No <br /> - _ ._� �l Obstructions removed 0 Yes 0 No If obstructions cannot be <br /> 1 . ( , ..J 1 removed, contact MOH <br /> W _ - -,•- -, -I- _ E \ '\ '-)"') I before sealing. <br /> - � <br /> ` T , ')+ . 7, USE <br /> -' ti.C. 1�Domestic 40 Monitoring 80 Heat Loop <br /> 20 Irrigation 50 Public 90 Industry <br /> 1 wl �\ ?)(e.tit LAS R 7 \I� 30 Test Well 60 Municipal 140 Commercial, <br /> 1 $�—� 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than 8. CASINGS) <br /> property address indicated above a Black 40 Threaded 70 <br /> ROBERT WAAG SAME 2[)Galy. 50 Welded <br /> 3[]Plastic 60 Stainless Steel <br /> HARDNESS OF 2', in. to 70' ft. <br /> 3. FORMATION LOG COLOR FORMATION FROM TO <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> r <br /> j 9. SCREEN <br /> fi Screened well from_ ft. to_ ft. <br /> i (If known) <br /> .. 0 Open Hole from_ft. to_ ft. <br /> 10. STATIC WATER LEVEL <br /> 50 ft. VI below 0 above 02/02/92 <br /> land surface Date Measured <br /> 9 <br /> 11. WELLHEAD COMPLETION <br /> 10 Pitless Adapter 4Q Found Buried <br /> 20 Basement offset 50 <br /> 34 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> WELL LOCATED IN PIT ON NORTHEAST CORNER OF Neat Cement z0 Bentonite <br /> Grout material cement from7 O to 0 ft. cu. yds <br /> BASEMENT. . . — 1.5 bags <br /> MEASUREMENTS TANKEN FROM BASEMENT FLOOR. . . 13. NEAREST SOURCES OF CONTAMINATION , loor drain <br /> OFI <br /> feet 11 directio type <br /> Well disinfected before sealing? at Yes <br /> 14. PUMP 4 Removed 0 Not Present <br /> DISTRIBUTION OF COPIES: <br /> STATE OF MINNESOTA <br /> LOCAL CITY <br /> CUSTOMER FILE <br /> Type: 10 Submersible 31:1 L.S. Turbine 50 Reciprocating <br /> a Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks section or on back.) <br /> CUSTOMER COPY Other unused weil(s) on property? 0 Yes a No <br /> MALENKE WATER SERVICES Abandoned: 0 Permanent 0 Temporary 0 Not sealed <br /> OTHER 17. 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 /> 10,6 ,-.)-7,-)6, 1-( <br /> Licensee Bus ness Name License No. <br /> Address UJ (.. (21() -Y(14 1jt cc.—C -J <br /> PID# 06-117-23 33 0002 Signet_ .—OflY'l I' _,I,.(-• <br /> A rte. 0 Date .� �rQ <br /> /�_tA ,--It , ,'�r^ I''', Date c0 q - <br /> OFFiCIAL ABANDONED WELL RECORD (May be used for Property Transfer) of Driller <br /> IMPORTANT: PILE MITI MIND MYRO MALENKE / JESSE MALENKE <br />