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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) H 24 5 2 2 <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 y <br /> Orono 117N Sr 23W wr 10 NE SE NW 122 ft. 7/20/92 <br /> Numerical Street Address and City of Well Location or Distance from Road S. DRILLING METHOD (if known) • <br /> intersection 10 Cable tool 40 R 13 Driven 100 Dug <br /> 1120 Willow Drive S. Wayzata, MN 55391 20 Hollow Rod 50 Air 80 Bored 110 <br /> 30 Rotary 60 Jetted go Power Auger <br /> Show exact location of well <br /> (in section grid with 'X') Sketch map of well location 6. OBSTRUCTIONS <br /> N Weil obstructed 0 Yes ® No <br /> Obstructions removed 0 Yes 0 No If obstructions cannot be <br /> removed, contact MEIN <br /> W - ! - - x - • -I- - E before sealing. <br /> 7. USE <br /> Domestic 40 Monitoring BO Heat Loop <br /> - <br /> 20 Irrigation S0 Public 90 Industry <br /> S 30 Test Well 60 Municipal 160 Commercial <br /> 1 S1. <br /> in Air Conditionina 1lf_i <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than 8. CASING(S) <br /> property address indicated above 10 Black 40 Threaded 70 <br /> 3065 Lake Shore Drive 212 Gal v. 50 Welded <br /> Tom Vickerman Maple Plain, MN 55359 3E]Plastic 60 Stainless Steel <br /> HARDNESS OF 2 in, 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 /> 9. SCREEN <br /> ®Screened well from ft. to ft. <br /> (if known) <br /> 0 Open Hole from_ ft. to_ ft. <br /> 10. STATIC3WTER LEVEL <br /> 44 ft. ®below 0 above <br /> land surface Date Measured 7/20/92 <br /> 11. WELLHEAD COMPLETION <br /> 10 Pitless Adapter 4Q Found Buried <br /> 20 Basement offset 6J <br /> 30 Well Pit <br /> 16. REMARKS. ELEVATION, SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1®Neat Cement 20 Bentonite ?D <br /> Grout material 21/2 bags from 0 to122ft. cu. yds•10 <br /> New well was drilled 6/23/92 — <br /> Unique well #480292 — <br /> 13. ."IC.YCST 4OJGCCG Cr CGFTAAlhATIUN <br /> feet direction type <br /> Well disinfected before staling? 0 Yes <br /> 14. PUMP ®Removed 0 Not Present <br /> Type: ID Submersible 30 L.S. Turbine SJ Reciprocating <br /> 22;Jet 4:3 Centrifugal 60 <br /> CITY Oc 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> ORONC _ active wells in remarks section or on back.) <br /> l5 1 E 0_'1l_ Other unused well(s) on property? 0 Yes ®No <br /> Abandoned: 0 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 /> S F(' 2 5 1992 Stevens Well Drilling Co. 27194 <br /> L,canm1 Highway 12 WeNome <br /> slten:e No. <br /> Address Ma le P1 NN 55359 <br /> Signed / ate 7/20/92 <br /> Joe Stevens ate 7/20/92 <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> IMPCPTART: rlla WITH DIKED <br />