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STATE OF MINNESOTA DEPARTMENT OF HEALTN <br /> ABANDONED NELL RECORD <br /> t. �oc�rtow aF wEu MINNESOTA UNIQUE WELL N0. H81772 <br /> County Name (leavt blank 1f not know�) <br /> Henne in <br /> To�nship M�or Townsntp HumDer Renge Number Sectton No. Fraction a, uELL DEPTH (to�pleted) Oate se�led <br /> N E 4 4 of y <br /> Orono 117N 5' 23W w� 20 NE NW NW 95 f`' 10/9/92 <br /> Numeritai Street Address and City of 4e11 Lota[1an or Distance fron Ro�d 5. DRILLIN6 METHOD (if knawn) <br /> Incersection 1�Cable tool i0 Reverse 7[]Oriven 1�Dug <br /> 2665 Casco Poi nt Road Orono 55392 �S]Ho�,aM Roa `,�]Atr �]Bored ��p <br /> Shor exact loc�tton of well 3Q Rot�ry 60 Jetted 9(]Power Auger <br /> (in sectlon grid vttA "X') Sketch nep of wll loc�tlan <br /> N 6. OBSTRUCTIONS <br /> �ell obstruct�d Q Yes &] No <br /> - �X - : •- -• ODstructtons rNov�d Q Yes []No If oDstructtons cannot Ce <br /> . I <br /> re�oved, conGct MOH <br /> M _ : _ : � � _ <br /> . - ' 'I- � E btfore s��ling. <br /> - _ :_ : : : T �. �sE <br /> - -, y.ri. 1[H Donestic �Monitoring �He�t loop <br /> .�_ _;, _ ' : � 20 Irrigatton 50 Public � Industry <br /> 3[]Test 11e11 6(]Municipal 1C[]Cosercial <br /> $ <br /> �---l +iL 7[]Mr Condittoning 11[f <br /> 2. PROPERTY ONNER'S NAME Mailing Address if different than 8. CASING(5) <br /> property address tndic�ted aDove 10 Black 40 Threaded 7[� <br /> 2665 Casco Poi nt Road 2�Galv. 5(]y�)d�a I <br /> B. Chuck Downey Wayzata, MN 55392 3[]Plastic 6psu��i�:: Steel <br /> HARDNE55 OF <br /> 3. FORMATION l06 COLOR FORlNTION FROM 7p 2 tn, to /�, <br /> If not known, indlcate formation log froa new well or nearby well. 1n, to ft. <br /> 9. SCREEM <br /> �Scrten�d wl l frw_ ft. tp ft. <br /> (If known) <br /> �Open Hole fro�_ ft. to_ ft. I <br /> 10. STATIC WATER LEVEI i <br /> 45 re. p o.iow ❑,oa�. <br /> ��na :urtace O�te Measurca 10/9/92 <br /> I1. YELLHEAD LOMVLETiON <br /> 10 Pltless Adapt�r �Faund Buried <br /> 2Q Basement offs�t � <br /> 30 Well Ptt <br /> 16. REMARKS, EIEYATIOX, SOURCE OF DATA - CASIN65 REMOVED, CASIN65 PERFORATED, ETC. <br /> 12. GROUTING INFOItMATTON <br /> l�Neat Cenent 2�Btntoniq � <br /> Graut wterlal j h�n s froo�to� ft, cu, yds.� <br /> ��^ <br /> _. — _� <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> _ feat dtrection �y� <br /> Mell disinfect�d befar� seallnyJ � Yes <br /> 14. VUMV (�Reoored �Not Present <br /> TYDe: 1[� Subo�rstble �]L.S. Turbine �Reciprocating <br /> 20 J�t �Centrifugal fi[� <br /> 15. EXISTIN6 YELLS (P1��s• sketcA lacattons of abandon�d �nd <br /> �ctiv� w�11s in rs�arks sectton or on back.) <br /> Oth�r unus�d wtl(s) on prop�rty7 �Yes � No <br /> Abandoned: []Farsan�nt �Te�porary �Not sealed <br /> 17. MATER MELI CONTRACTORS CERTIFiGTION <br /> Thfs �+ell was sealed under uy Jurisdtction and this report <br /> is true to th� best of my knowledge and Eeltef. <br /> te en W 1 Drillin Co. 27194 <br /> Llcense� Bustn�ss Na�e Ltcens� No. <br /> Address <br /> Slgned _ � ��1�.,�� 2 Lti_, D�te <br /> Ranriv ,lnhncnn o.0 1 n� <br /> FFICIAL ABANppqEO YEIL fiECOitD (May be us�d for Property Transfer) Na�e of rill�r <br /> I!@CRTAIi'r llLd MIT9 �6gp <br />