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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 Hennepin - <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> N E 4 4 of 4 <br /> or or ft. <br /> Orono 118N s 23W V 33 SE NE SE 157 06/07/91 <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) <br /> Intersection 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> 225 North Willow Drive Long Lake 20 Hollow Rod so Air 40 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 6. OBSTRUCTIONS <br /> N Well obstructed 0 Yes ® No <br /> Obstructions removed 0 Yes O No If obstructions cannot be <br /> i removed, contact MOH <br /> before sealing. <br /> W _ i. - - • - - - -1 - E <br /> : : 1 `X r 7. USE <br /> - • <br /> - 7 ,•- -i y In Domestic 43 Monitoring 80 Heat Loop <br /> 2J irrigation 5J Public 90 Industry <br /> 30 Test Well 60 Municipal 100 Coammercial <br /> - t SL 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than 8. CASING(S) <br /> property address indicated above 0 Black 40 Threaded 70 <br /> Jim Dillman 2ti Gals. 50 Welded <br /> 30 Plastic 613 Stainless Steel <br /> HARDNESS OF 3 1n. to 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 /> Topsoil Black 0 2 9. SCREEN <br /> 0 Screened well from_ ft. to ft. <br /> Clay Yellow 2 18 0 Open Hole from_ ft. to_ ft. (If known) <br /> Clay Blue 18 37 10. STATIC WATER LEVEL <br /> e <br /> Clay/Gravel Blue/Bra-in 37 62 lOQnd surface )Date Measured 06/07/91 <br /> Clay Blue 62 67 11. WELLHEAD COMPLETION <br /> Gravel Browr. 67 72 10 P,tle:. Adapter 40 Found Buried <br /> 20 Basement offset 50 <br /> Clay Blue_ 72 112 30 Well Pit <br /> 16. REMARKS. ELEVATION, SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> Clay/Sand Blue 112 138 i®Neat Cement 20 Bentonite 30 <br /> Clay Blue 138 150 Grout material 5 bags from 0 to 1571. cu. yda,28 <br /> Gravel Red/Black 150 157 <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> feet direction type <br /> Well disinfected before sealing? 0 Yes <br /> Formation log taken frcan new well drilled 14. PUMP ®Removed _0 Not Present <br /> 05/14/91. Unique Well # 478365 Type: 10 Submersible 30 L.S. Turbine 13 Reciprocating <br /> 20 Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks section or on back.) <br /> Other unused well(s) on property? 0 Yes E0 No <br /> Abandoned: J]Permanent 0 Temporary 0 Not sealed <br /> 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 /> Stevens TTA11 nri11ing 27194 <br /> 624LoCe ignway "17 West License No. <br /> Addre_ _T__1 ple P in, DIN 55359 <br /> Signed / IL✓i Date 06/07/91 <br /> Tim Stevens Date 06/07/91 <br /> ,FFicIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> rip ' rrt r1L2 NTTMT VI= <br />