Laserfiche WebLink
_ _ <br /> STATE OF MINNESOTA �EPARTrfEPiT OF HEALTH <br /> " laBANDONED NELL ItECORD <br /> 1. �xnrton oF ve��. MINNESOTA UNIQUE WELL N0. <br /> (leave blank tf nat known) _ <br /> Cau�ty Haax ��� <br /> Townzhip Mame Townshi Numbe; Range Number Section No. Fraction 4. 41ELL DEPTH (completed) Date sealed <br /> �rw�-�- l C 7`S� ��%� � k k of k �(-7t. �J' ' r� ` '!/ <br /> l% J C/ <br /> Numertcal Sireet Address and C1ty of Well location or Distance from Raad 5. �RZLLING METHOD (if knoxn) <br /> Intersection Cable tool 4�Reverse 7[]Driven 10C1�ug <br /> � P�' }� � 2f]Hollow Rod 5[]A1r �]Bored 110 <br /> 7�v ���. 3[]Ratary "a 60 Jetted 9�Poaer Auger <br /> Show exact locatton of 11 <br /> (in sectton grtd �tth "X") Sketch map of well ',:cation �% 6. OBSTRUCTIONS <br /> N 41e11 obstructed�Yes � No <br /> _ � _ _ _ _ ._ _� � Obstructlons remored�Yes (�No If obstructions cannot be <br /> � � � recaved, contact MDH <br /> ' ' � � before sealtnq. <br /> ►+ - - - - • - - -I- - E <br /> - ` . : , T —3 � �� �. �sE <br /> ' - ' ' ' y„�. I�Domestic 4❑�,nitoring 80 Heat Loop <br /> � ' _ � I �,{f•(/�' �� 20 Irrigation �]Public 9� Industry <br /> � ' 1 �� � 3�Test Nell 6�Municipal 1C0 Cortmercial <br /> r--1 SL 7[]Air Condittoning 11[]_ <br /> 2. PROPERTY OMNER'S NAME Mailing Address if dtfferent than 8. CASING(5) ' • <br /> i� ,� � property address indlcated above �lack 4�Threaded 7Q <br /> / �-- <br /> 2[(Galv. 5[�Welded <br /> 3L]Plastic 6�]Stainlesz Steel • <br /> HARONESS OF <br /> 3. FORMATION LOG COLOR FORMATION FROH TO �in. to J� ft. <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 /> �— (I` known) <br /> �i ,f � �Open Hole from_ ft. to_ ft. <br /> 10. STATIC WATER LEVEI <br /> ��! ft.�pelow []above , <br /> land surface Date Mensured �1��I� <br /> {._,. 11. WELLHEAD COHPLETION <br /> i1� Pitless Adapter �Found Buried <br /> �Basement offset 'j] <br /> 30 Well P1t <br /> 16. REMARKS, ELEVATTOtI, SOURCE Of DATA - CASINGS REMOYED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1�-Neat Lement 2�]Bentonite � <br /> Grout material �l from Tf to �ft. cu. yds <br /> — — --� <br /> 13. REST SOURCES OF CONTAMINATION <br /> v feet _� directton ��.�.,_ type <br /> Mell disinfected before sealingt ,�Yes <br /> 14. PUMP [�,Rertqved �Not Present <br /> Type: 1[�Submerslble 30 L.S. Turbine �Reciprocating <br /> �,)et C�Centrifugal 6[� <br /> 15. EXISTING WELLS (Please sketch locatlons of abandoned and <br /> active we11s 1n remarks section or on back.) <br /> Other unused well(s) an property7 �Yes �No <br /> Abandoned: [� Permanent �Temporary [�Not sealed <br /> 17. wATER WEIL CONTRACTORS CERTIFICATION <br /> This well was sealed under my jurisdiction and this report <br /> is true to the best af my knowledge and belief. <br /> censee siness Nam n License Na. <br /> �C.Y <br /> Address � ,J` ' �(G�-� ' <br /> Signed c. C Date ,�- <br /> '� �ate -' ,e '-'�j <br /> FFICSAL ABANDONED YELL RECORD (May be used for Property Transfer) Name of ri er <br /> IXPCYtT]IAT: PZLS (�7TH DSBD . <br />