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ME <br />STATE OF M [ iN ESOTA DEPARTMENT OF HEALTH <br />ABAND011W..D WELL REC'ORD <br />1. LOCA11411 OF WILL <br />County Nate % � <br />Townswip Noxi Township NiAer Range Nufter I Section No.1 Fraction <br />C7_l E t s of t <br />C��t,•U�-,� / ! ) Sr j 3 � <br />/ v c� <br />Numerical Street Address and City i f yp'i Location or Distance from Road <br />M <br />Show watt location of weii <br />(in sectION grid with 'Y') <br />N <br />MINNESOTA UNIQUE WELL NO. <br />(leave blank if not known) f I <br />a. WILL DEPTH (completed) <br />,-)6)ft. <br />Dau staled <br />S. OR I L L I N6 MIE T1t00 (ft a nape ) <br />a Cable tool 40 Ne.ent 70 Driven IC0 Dug <br />20 10011 ow Rod SD Air 10 isred 110 _ <br />10 Rotary 60 Jetted ill'] Fewer Auger <br />Sketch mep of wall location 6. ORSYINKTIO" <br />Well obstructedi2Yes ❑ Ne <br />Obstruct ons reme"d (eYes ONO If obstructions cannot be <br />relieved. contact ON <br />before waling. <br />5 <br />►-�-� 1 w <br />2. PROPERTY OMA'S NA1E Mailing Address if different than <br />_ * _ _O property address indicated above <br />"Afl S OF <br />1. FORINT 1011 L06 COLOR FORINT ION FROM <br />If not known. Indicate fdrfation tog freM new well or nearby well. <br />7. USE - -- <br />1m Omstic 40Menitorl" loneat Loop <br />20 irrigation 10 ►Witt go Indwstry <br />U Test W11 1 i0 AM i i i pe l MOL] Coa>arerc 4 0 1 <br />70 Air Conditioning 110 <br />a. CASIN6(S) <br />10 Black 40 Tkmdid Cl <br />20 6a 1 v . 10 lie 1 ded <br />30 Plastic 40 Seamless SU.1 <br />TO 10. to i ft. <br />in. to ft. <br />I. SCREEN <br />❑ scroomed well frees 1-1�7-f t. to -i:kLlft. <br />(!f thorn) <br />❑ Open Mole from ft. to ft. <br />10. STATIC TER LML <br />ft. ® below ❑ move <br />load svrfoce Rett Measured <br />11. WELLHEAD COMPM101 <br />1❑ Pitless Adopter V ►own! Buried <br />28 114"ment offset <br />10 will Pit <br />16. RFOARKS, ELEVATION. SOURCE OF DATA • CASINGS REMOVED. CASiOGS PERFORATED. ETC. <br />12. GR% flN6 INFORWTION <br />1n Nest Cewent 20 News Ito 10 <br />Grout material '! from 4�-to--e ft. cu. yes <br />13. NEAREST SOURCES OF CONTAMINATION <br />feet j tf-` direction --A-. type <br />If Wall disinfected before sealing? ® Yes <br />i 14. PUMP ® Romm"m ❑ Not Present <br />Type: 1(_i Submrsible 10 L.S. Turbine !0 Reciprocatinq j <br />41 Jet 40 Centrifugal 110 <br />i <br />OFFICIAL AL%Ntx`.NEO WELL RECORD (Limy be used for Pr-iperty Transfer) <br />1!4M!Y! t FUN RR 17 DINVO <br />1S. EaiSTIN6 WILLS (Please sketch leutiows of soaneenod and <br />active wells in remorks section or ,n batt. <br />Other unused wei l (s) on property? (3 Yes jo No <br />Abandonea: ❑ Peri mmt ❑ Temporary ❑ Not sealed <br />17. WATER WV L CONTRACTORS CERTiFiCATiON <br />This well was sed led under my jurisdiction and this report <br />Is trU* to the best of way knowledge and belief. <br />Address <br />■■N <br />MINNESOTA UNIQUE WELL NO. <br />(leave blank if not known) f I <br />a. WILL DEPTH (completed) <br />,-)6)ft. <br />Dau staled <br />S. OR I L L I N6 MIE T1t00 (ft a nape ) <br />a Cable tool 40 Ne.ent 70 Driven IC0 Dug <br />20 10011 ow Rod SD Air 10 isred 110 _ <br />10 Rotary 60 Jetted ill'] Fewer Auger <br />Sketch mep of wall location 6. ORSYINKTIO" <br />Well obstructedi2Yes ❑ Ne <br />Obstruct ons reme"d (eYes ONO If obstructions cannot be <br />relieved. contact ON <br />before waling. <br />5 <br />►-�-� 1 w <br />2. PROPERTY OMA'S NA1E Mailing Address if different than <br />_ * _ _O property address indicated above <br />"Afl S OF <br />1. FORINT 1011 L06 COLOR FORINT ION FROM <br />If not known. Indicate fdrfation tog freM new well or nearby well. <br />7. USE - -- <br />1m Omstic 40Menitorl" loneat Loop <br />20 irrigation 10 ►Witt go Indwstry <br />U Test W11 1 i0 AM i i i pe l MOL] Coa>arerc 4 0 1 <br />70 Air Conditioning 110 <br />a. CASIN6(S) <br />10 Black 40 Tkmdid Cl <br />20 6a 1 v . 10 lie 1 ded <br />30 Plastic 40 Seamless SU.1 <br />TO 10. to i ft. <br />in. to ft. <br />I. SCREEN <br />❑ scroomed well frees 1-1�7-f t. to -i:kLlft. <br />(!f thorn) <br />❑ Open Mole from ft. to ft. <br />10. STATIC TER LML <br />ft. ® below ❑ move <br />load svrfoce Rett Measured <br />11. WELLHEAD COMPM101 <br />1❑ Pitless Adopter V ►own! Buried <br />28 114"ment offset <br />10 will Pit <br />16. RFOARKS, ELEVATION. SOURCE OF DATA • CASINGS REMOVED. CASiOGS PERFORATED. ETC. <br />12. GR% flN6 INFORWTION <br />1n Nest Cewent 20 News Ito 10 <br />Grout material '! from 4�-to--e ft. cu. yes <br />13. NEAREST SOURCES OF CONTAMINATION <br />feet j tf-` direction --A-. type <br />If Wall disinfected before sealing? ® Yes <br />i 14. PUMP ® Romm"m ❑ Not Present <br />Type: 1(_i Submrsible 10 L.S. Turbine !0 Reciprocatinq j <br />41 Jet 40 Centrifugal 110 <br />i <br />OFFICIAL AL%Ntx`.NEO WELL RECORD (Limy be used for Pr-iperty Transfer) <br />1!4M!Y! t FUN RR 17 DINVO <br />1S. EaiSTIN6 WILLS (Please sketch leutiows of soaneenod and <br />active wells in remorks section or ,n batt. <br />Other unused wei l (s) on property? (3 Yes jo No <br />Abandonea: ❑ Peri mmt ❑ Temporary ❑ Not sealed <br />17. WATER WV L CONTRACTORS CERTiFiCATiON <br />This well was sed led under my jurisdiction and this report <br />Is trU* to the best of way knowledge and belief. <br />Address <br />