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STATE OF NINNESOTA DEPARTHM OF HEALTH <br />ABANDONED WELL RECORD <br />1. LOCATION OF WILL <br />County Now Monnonin <br />TowafMp Rase Towth p NMaoer Rang Number SoctlM ft. Fraction <br />N [ 41 of is <br />Orono rf °r r S NE <br />/ E <br />Numerical Strut Address and City of Well Location or Olstaws free Need <br />Ietortatlen <br />1937 Fagerness Point Road Wayzata, MN. 55391 <br />Sho■ exact location of wall <br />(In soctlon grid ■Ith 'I') Sketch eep of "all location <br />N 0 <br />WN 0 <br />W <br />I <br />1E Rnrt.1 <br />ad. <br />1 <br />o-- l w le <br />2. FROKRTT OWRER'S NAIL Nel11ne Address If different then <br />property address Indicated above <br />Richard Roberts SAME <br />NUDIISS OF <br />3. FORMATION LOG COLON FORNATION FROM TO <br />If not keeUn, Indluw forest.. -.q from raw roll or nearby ■all. <br />Drift I I 1 0 61' <br />REINRIS. ELEVATION. SOURCE Of aTA - CASINGS 11E310.0. CASIOU KRFORATED. ETC. <br />Grout 2" Well Approx. 61' Deep <br />2 Bags Cement <br />4 Lbs. Bentonite <br />Men, Labor, Rig and CaTent Crout Pu1Tlp <br />:FICIAL AGAMOOKO YELL ACCORD (Nay be used fed Property Transfer) <br />r�. .war. -- ...... <br />MINNESOTA UNIQUE WELL NO. <br />(lee" blank If not knew) <br />•. IRLLKPT{M (completed) amid tooled <br />(C I ft. 3I 10 I 1 q I <br />S. 04LLL146 NRNOO (1f ►new) <br />Cable tool 40 Reverse 70 ONpes lao 0" <br />ID Mallow Rod Sfl Air EQ veered Ito <br />30 Newry IQ Jetted 110 power A■pr <br />G. MTRIICTIONS <br />Melt obstrwetod� ', Ne <br />Optrectlap ►tea Tel Q fed If obstroctlMt cahoot be <br />removed. concoct N1N1 <br />before t°a11M. <br />7. <br />(kowsstlt Q IM/torl°O 10 Meet loop <br />4--] Irrigation 10hbl lc 0 Issuttry <br />30 Test Welt lO IkelNpal IIO C on rcIaI <br />C Air Ceaaltlealq 110 <br />IT -IN <br />10 Nlbtk <br />�kThreeaad 70 <br />�Okfislp. <br />10 IUldad <br />30 Plastic <br />Q Stateless Steel <br />a <br />IN. w _ 57 ft. <br />IN. is n. <br />scan <br />aSeroaona wall FveN 57 n. to 61 n. <br />(I/ kaaxel <br />❑ ope Nets <br />from _ n. to — n. <br />below Q abwa j o <br />we Oaks Ibwred <br />11. WELLIIAN COPLETla <br />0 Pltless Adepter Q 10ued [Myles <br />20 so e t offset In <br />Wen Plt <br />12. VWTIM INIOMtTION <br />7F Wet CA ont 10 watontte 30 <br />Erb■t •terlot Iree �ta ft. cu. yea_ <br />13. IIAKST SOURCES OF CWTMINtTIW <br />feet Hrettlen tyM <br />Mall HtlefectM bet" eeellog? Q This <br />ld. PUMP M kMvod Q %t MaMt <br />Typo: I[) Subarslbh 30 L.S. TurNee 10 Roclprocatlep <br />iiJet 40 Costri"I 10 <br />16. EIISTIRR MILLS (YINee swUll locations of abndoe°a add <br />eettve wilt le red see Ion N M book.) <br />Other Meuse( ■Ifll(e) M p C3 Tom F Q Tek ® M <br />AbendennM: Fereeeeet Q Tomporaryr 0 t Ion <br />17. YATER WILL CON/MCTONS CERTIFICATION <br />This wall we owled ■ever op Jurisdiction and this ro ert <br />Is true to the beat <br />of dry kee■lodp W belief. <br />DON SWDOLA WELL DRILLING OD., INC. <br />LIcMaM W1eess Use LlcMN Ne. 271 , <br />Adorest , <br />_ <br />92 <br />. ,,.. ,. — gets <br />doe of Ib11lop <br />345 <br />