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� STATE OF MINNESOTA DEPARTMEN�...QF HEALTH � <br /> !�en�Ecbkb`�`°:, <br /> 1. LOCA710N OF YELL M(enEe�lank N fQ oE W own)N0. <br /> Gounty Name U _. <br /> �L.:._ <br /> Township Name Townzh Number Range Number Section No. Fraction 4. WELL OEPTH (complettd) Date sealed <br /> E h +� o f 'y <br /> � ��"``/r P/ sr �-� �j ! C� �� fc. y..� _ lC,` �,i <br /> ��' \ <br /> �., V <br /> NUmerical Street Address and City of Neli Location or Oistance �`ri d 5. DRILLING METHOD (if knoxn) <br /> Intersection �� 1�Cable tooT 4[�Reverse 7[]Driven IC�Dug <br /> ���� �� , � 2[J Nollaw Rod 5[]Air 8�]Bored 11[] <br /> ;hoa ezatt location of well <br /> 30 Rotary 6�Jetted 50 Power Auger <br /> (in sectton grid �ith "X") Sketch map af well location 6. OBSTRUCTIONS <br /> � Mell obstructedc�.Yes � No <br /> _ � _ _ _ ;_ _. _ 2�� � Obstructtons removed�]Yes (]No If obstructions cannot be <br /> � � � ' � removed, contact MDH <br /> , > �� <br /> y� _ ; ; y _I_ � _ E O� before sealing. <br /> _ , , � � j �. �SE <br /> " '- ' '' ' 4.,�, s� 1]�6omestic 9[�Monitoring 80 Heat Loop <br /> _ <br /> ; _; _ ; : I ('(� 20 Irrigation 50 PubliC 90 Industry <br /> 1 % 3[J Test iiell 6(]Huniclpal 1C[]Commercial <br /> s � <br /> � 1 +�L 7�A1r Conditioning 11[] <br /> 2. PROPERTY OWNER'S(�NAME Ma111ng Address if dlfferent than 8: CASING(S) � <br /> � � y M property address indtcated above 1�Black 4�Threa.ded 7(] <br /> �Cl <br /> 2[�6alv. 5[�Welded <br /> 3L]Plastic 6�;tainless Steel � <br /> HARONESS OF <br /> 3. FORMATIOH lOG COLOR FORMATION FRON Tp �Tn. to�ft. , <br /> If not known, indicate formation log fram new well or nearby wello 1n. to ft. <br /> 9. SCREEN /� <br /> �Screened well from��ft. t67�_ ft. <br /> — — — (I' known) I <br /> C J ❑Open Hole fron ft, to ft. <br /> 10. STATIC WA7ER LEVEL <br /> �� ft. � below (�above <br /> land surface Date Measured <br /> 11. 41ElLHEAD COMPI.ETION <br /> 1� Pitless Adapter 40 Found Buried <br /> � 2(�Basement offset '� <br /> 3�Well Pit <br /> 16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTIN6 INFORWITION <br /> l�j-Neat Cement 2[]8entonite � <br /> Grout material � from�to� ft. cu. yds <br /> � <br /> i — — <br /> � 13. MEAREST SOURCES OF CONTAMINATION � <br /> /'U feet y��_ directlan '��_'�'7�='—tYPe <br /> Well disinfected before sealingt Q] Yes <br /> 14. PUMP �Reoaved �Not Present <br /> Type: 1[I Submersible 3�L.S. Turbine '.�(Reciprocating <br /> �Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locattans of abandoned and <br /> I active we11s in remarks section or on back,) <br /> Other unused w�ll(s) an propertyt �Yes � No <br /> Abandoned: [] PermanenY �Temporary �Not sealed <br /> 17. NATER uELI CONTRACTORS CERTIFICATION <br /> This well was sealed under my Jurisdiction and this report <br /> is true to the bes of my knovrledge and belief, <br /> �- . w J7 > 7 � <br /> Llcensee Business Name � ��tcens N <br /> C <br /> �-- • <br /> Address <br /> Signed�ve ✓�_Date .r-�7 c! <br /> Date �� - � <br /> FFICIAI ABAIIpONED 4ELL RECORD (May br used for CroDerty Transfer) Name of 111er <br /> ZXPCYtTA1VT: PZLS WITH DSBD . <br />