Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
- , , __. .._ . -- - - - ..> - <br /> � . STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> .1. LOCATION OF MELL MINNESOTA UNIQUE WELL N0. <br /> (leave blank 1f not known) <br /> County Nam� /� <br /> ' `7 j— � <br /> J <br /> Tornship Naer Township b�L Range Number Sectton No. Fraction 4. MELL OEPTH (completed) Date sealed <br /> J <br /> � 1 Sr CG5 7 �'/11��1 �' / ft. r d- 3 � <br /> Numerical Street Address and C1ty of ell lotatlon or Dtstantt from Road 5. DRILLING METH00 (1f known) <br /> Intersectton 1[]Cable tool CQ Reverse 7[J Dr1v�n 1(�]Du9 <br /> � � � 2�Hollow Rod 50 A1r �Bored 11(] <br /> SAow exact location ot well <br /> 30 Rotary 6�Jetted 90 Parre�Auger <br /> (tn section grid rtth 'X') SketCh nap of well locatlon 6. OBSTRUCTlONS <br /> N wetl oestructea Q res f�no <br /> _ ► _ _ _ ._ Obstructlons reanred Q Yes �No If obstructlons cannot be <br /> � � � � remored, tontu t MDH <br /> W _ . -• - � -I_ � - E before sealing. <br /> . . <br /> : ; ` T �. �SE <br /> ' y„�, �Domestic �Monitoring �Heat Loop <br /> � : I - <br /> 2[�Irrlgatlon 5�Pub11e 9� Industry <br /> -'- • -'- - <br /> ---- S . .iL �a:: �e�i oV ltunictpa7 1cL Commercl�l <br /> �--�—1 .iL--+ 7[]Mr Conditioning 11[] <br /> 2. PROPERTY OWNER'S NANE FIa111ng Address if dtfferent tAan 8. CASING(5) <br /> ����` ` property address tndicated above • jL7}�Black IQ Thnaded 7[] <br /> � 2fl Galr. 50 M�ldtd <br /> 3j]Plastle 6(]SUtnless Steel <br /> NARDNESS OF � tn, to ` _ft. <br /> 3. FORMATION �OG COLOR FORWITION FROM TO <br /> If not known, indiute formatlon log fros new well or nesrby well. tn, to ft. <br /> 9. SLREEN <br /> ❑Screened w�l l tro�_ft. to_ ft. <br /> (I! knorn) <br /> �Open Hol• fro�_ft. to_ ft. <br /> 10. STATI� M4ILR LEYEL <br /> �s ft.�below �abor� / Q . <br /> � land surfac� Oat� Meesured ` [ <br /> 11. WELLNEAD COMPLETION <br /> �Pitless Adapter �Found Buried <br /> 20 BasemenL offset �Q <br /> 30 Nell P1t <br /> 16. REMARKS, EIEVATION, SOURLE Of DATA - CASIN6S REMOYED, CASINGS PERFORATED, ETC. <br /> ' 12. GROUTING INFORMATION <br /> 1�]Neat Cement 2�Bentontte � <br /> Grout materlal�P��from��to�ft. cu, yds <br /> � — --- -- —� <br /> 13. NEAR�F,$7 SOURCES ��f CONTAMINATION <br /> � feet J dlrectton ,.l1 D�.t�1 ��rpe <br /> • Well dlsinfected befon sea11ng7 []Yes <br /> 14. PUMP �]Removed �Hot present <br /> Type: 1[I Submersible �L.S. Turbine 5�Rectprocating <br /> 2�Jet �Centrlfugal 6� <br /> 15. EXISTING WELIS (Pleas� sketch locattans of abandoned and <br /> � 1 active wells 1n rcmarks sectton or on back,) <br /> ,� Other unused i+ell(s) on propertyT �Yes �'tlo <br /> Abandoned: �Permanent �Temporary �Not sealed <br /> 17. WATER WEII COIITRACTORS CERTIFICATION <br /> This wetl was sealed under my Jurlsdlctton and this report <br /> is tru to the be of my knowledge and belief. <br /> - r r � / <br /> ��1 f�\� `� �t i���;� .�... Gr/ �1..lL� <br /> Llcensee Business Ilame License No. <br /> Address � �s`�z�v� � <br /> 51 /� te .L <br /> � " te •Z <br /> 9FfICIAI ABANOONED YELL QECORD (May be used for Vroperty Transfer) Name of Dr111�r <br /> ZXPpZTA11ITr lILE MZT9 DSdD <br />