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STATE OF MINNESOTA DEPARTMENT OF HEALTN <br /> ABANDONED WELL RECORD • <br /> 1. �ot�TloN of w[ll MINNESOTA UN[QUE MELL N0. 1 <br /> (leave bL ok 1/ not known) � � <br /> c�°°`Y "•�` Heruze in <br /> Tovns�l0 Nae�t� To�nsAlp Number Aange Number S�ctlon No. Fr�ctten �. MELI UEVTN (�ospleted) Oate sealed <br /> M E ti � ot y <br /> �r�fl..--.--�. _ Sr Mr 05 rc. 9-24-90 <br /> Nmneric�l Stnet ddreis nd C1ty of Nell Lou tton or OtsUnct /ron Road 5. ORILU NG METH00 (/I knowe) <br /> �r fntersectlon 1�Cable tool �Rev�rst 7(]Driven I[Q Dug <br /> 2824 Casco Poi.ntl Road� ��Jayzata, r�1bl 55391 zp Hoiio� Rod S[�Mr ep eo�.e >>p _ <br /> 3�Rat�ry 60 J�tted �Porer Auger <br /> Sho� exact loutton of rrll <br /> (in sectton qrtd vitn "lt") Sk�tch e�p of �elt loc�N on 6. OBSTRUCifONS <br /> �___ _- <br /> N Well oDstructed�Yes � No <br /> � ._ ` Obstructlons nmov�d Q Yes ❑No If obstrucN ons cannot De <br /> . . � removed, contaCC MOH <br /> M _ � - • + -I- ` - E before sealing. <br /> ; : , ; T �. �sE — <br /> ,_ , . _ y� 1�Domestit �]Monitoriny �Heat Loap <br /> _' <br /> ; ; ; : � 2[] Irrlqallon 50�ubI1C 9[] lndustry <br /> �[]Test 4e11 6�Munlclpal 1CQ Commerctal <br /> S 70 Mr Condttiontng 110 <br /> r--1 +i L — <br /> 2. PROPERTY OWNER'S NAME Mailing Address I! 0lfferent th�n 8. CAS(NG(5) <br /> proDerty address indlc�ted above 1�Bleck /�Thr��ded 70 � <br /> Miriam Johnson �Galv. 50 4elded <br /> JQ V1asNc 6[]St�tnless Ste�l <br /> MARONESS OF 3 <br /> J, FORMATION LOG COLOR FORWITION fROM TO �^• t� ft. <br /> If not known, 1ndlute fornutton log lrom new rell or n�arby vell. 1n. ta ft. <br /> 9. SCNEEN <br /> �Scre�ned w�ll from_ it. to _ ft. <br /> (If known) <br /> �ODen Hole fro�n_ it. to _ (t. <br /> 10. STATIC M�I�R LEVEL <br /> ��-S tt.�j] Dalow ��Dove <br /> l�nd sur/�ce D+te Meesured 9-24-9 0 <br /> 11. uEILHEAD COMVLETION <br /> l� Pltless Rd+pt�r �Founa Burted <br /> 20 Basement oNset 5Q <br /> l�Hell Dtt <br /> t6. NEIMRKS, ELEVATION, SOURCE OF OATA - CASINGS NEMOVED. CAS[NGS PERFORATED, ETC. <br /> t2. GNOUTING INFONMATION <br /> 1�Ne�t Ce�nt 2[]Btntoett� � <br /> House has been sold. ��o�c �,�.�,.� 3 bagi�r�o�Qco85 +�. ��. Y�= 1 <br /> I7. NEAREST SOURCES OF CONTAMINATION <br /> /tet dlrecN on CyDe <br /> � /� 4e11 dlsinfect�d D�fore se�ling7 ❑ Yes <br /> � � <br /> � � IC. �UNV �Reenved �Not Present <br /> n- Type: t[� SubnarslDle �L.S. Tur�ine � Reclprocating <br /> 'V <br /> 2�Jet �]Centrlfuqal fi0 <br /> � <br /> >� 15. EXlSTING �ELLS (ile�s� sk�tcA loutlons ot abanGoned and <br /> �ctive w�lls tn remarks s�ctlon or an uack.) <br /> Oth�r unus�d wll(�) on propertyt �Yes � No <br /> Ilbandoned: �V�r�an�nt �Tampan ry �Not sealed <br /> V. MATER WELL CONTRACTORS CEATIFfCATION <br /> Thts well was s�+l�d und�r my Jurlsdictlon and tnis re0ort <br /> I: crue to th� Dest of my knowled9e end belle�. <br /> Stevens Well Drillinq 27194 <br /> "�•��240�H��qhwa� 12 we�te�s• N�. _ <br /> Addreis I1 � <br /> Siqn�d � �✓ Oate 9-24-90 <br /> Dick o,�. 9-24-90 <br /> OFfICi�l A6A1100NED �ELL AECOQD (May b� us�a !o rooertY Trans/�r) N�iw of Drtll�r <br /> IJIPCRTANr r !I Ld MI1'S DdED . <br />