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STATE OF RINNESDTA DEPARTMENT OF HEALTH <br />ABANDONED WELL RECORD <br />c ^, _ <br />t. IlliAflM M If[ll <br />MINNESOTA UNIQUE YELL ' -1 �._' <br />• <br />(leew blank if net know <br />ew Cty Ilex <br />Township OuM <br />tows le A1aeer <br />sense Number <br />Section M. <br />irKHea <br />.. WILL OEPTh (consist 4) <br />Do ed 0D� <br />■ <br />E <br />et <br />Orono <br />117 i <br />23 �r <br />17 <br />SW SW SE <br />o1.70/- <br />boserJcel stnmt a asd City of well leteUN <br />or Olstance frm bee <br />S. ONILLING INITIO) (If know) <br />✓> <br />, - <br />Cable tat 41311everse 10 Drlyea to urg <br />3457 Crystal Plac <br />Sbr Butt location or we�11 <br />� (1a NctIM grid f"1") <br />W <br />r— . +L& <br />)PENTT OWMN'S UK <br />:a, Mn. 55391 <br />Swatch Yp or .ell locatloo <br />v�u« <br />TE <br />A .. �. <br />to w. n <br />Malling Address if elf/eront than <br />oroporty addrass Indicated Aboyf <br />Jim Sampson I <br />KUMSS OF <br />T, FORMATION L06 COLON FOrMTION f%W TO <br />If not known. Indicate formation tog iron aew well or nearby wet <br />i❑wllow Add SUAir 10 Not - I1Q <br />30 burr 60 Jetted 10 power Aver <br />a. 06STNLKTI0"' <br />sell obtr.cted,gfe ❑ N. <br />0►ItructlNf reMpVN Ik Tef ❑ Re If obstrettlons Co-inot be <br />reMsved contact MON <br />t•.Ilq. <br />T. USE <br />1KDosopstic Q Nf.ltorl.E 40 most Loop <br />20 lr.lption 10 public 10 ledustry <br />30 Test Well Q Municipal IUD Co.u.rcial <br />20AJr Conditioning 110 <br />i <br />A. CASINGS) <br />19 E14ck IM TMNAN 1❑ <br />20 Galy. 10 Welded <br />10 Plastic ID stainless Steel <br />in. tn, —1d0 ft. <br />IN. to ft. <br />t. $CA[EN <br />❑ screened well from — It. to — ft. <br />(if thew) <br />1000n w1s f Wn, to" it. <br />10. STATIC WT[R LE141 <br />/t.14 below 0 as*" <br />lend serf Ka We 14450red 11—F-fe <br />It. VNEAD cowuTION <br />T/FItIes. Adapter Q know Well ad <br />20 Easswent offset 10 <br />20 wl I pit <br />RCMAARS. ELEVATION. BOUNCE OF DATA - CASIO" EEAMD, CASINGS KNFORATED. ETC. <br />IT. ZTINg INrONIMTION <br />Grout 4" Well Approx. 220' Deep Neat Combat 10 u.teNto 43 <br />4 Hours Labor, 2 Men & Grout Pump Grewt Material ►0-9 ft. cu. yet <br />11 Bags Cement — — <br />3 Bags Bentonite 0. AEAAEST Sowers OF CONTAMINATION ✓ <br />10, <br />FFICIAL AMIt WO WILL KCOAO (by he rood for Property Transfer) <br />IAAIa"Wro rZAR EQ!! iiiiiiiiiiiio <br />Nt dlrK.I@P . !X. type <br />well disinfected before seallepr 0 rr. <br />Is. ►w X NuWyed 0 rat Present <br />Typo: K Swho sable 20 L.S. Turbine C Reciprocating <br />10 Jet (3 cestrifupal 40 <br />15. (11STI06 WELLS (please skatcA letatless of abandoned and <br />ettiwe wells 1. re "D settle or o. Dock. ) <br />other roused wells) M Wesm►tyl ❑ its No <br />A aaddNd: 0 poreeaNt I1 Temper•ary ❑ t sealed <br />11. VAT(R WELL COIFYAACTM CERTIFICATION <br />This well was styled "Nor N Jurlsdlctles and this report <br />it us to the best of 4' knowled" and bettor. <br />James NeRe License <br />Address w'm <br />Slg , OeuLl_4A <br />— <br />�ii�k- <br />sew of Awe/ IM <br />