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., _r w. . _�, _ <br /> STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED V�lELL RECORD Z <br /> 1. LOCA7IOM OF �Ell M(eaEe�lank NtQ oE w own)NO. �� <br /> County name - <br /> Tornsnlp Mane Tornship mber Range Number Section No. Fraction 4. 4ELL DEPTH (completed) Date sealed <br /> U�v� G / �� ��� [ 7 k .4 of 'k 1 J � ft. � <br /> �- 7- �-� <br /> Nwnerical Street Address and CTty of Well Location or Dlstance from Road 5. ORILLIHG METHOD (if known) <br /> Tntersection / �j 7 /1 _ - ,/ L 2�]Cable tooi 4Q Reverse 7[]Driven lC[1 Dug <br /> ! /o�l S C.iCl'�/�.G✓✓C�''��LC J.. <br /> 2� Hollow Rod 50 A1r 8�gcred 11[] <br /> /l--�r�— <br /> Shor exact locatton of we11 <br /> 30 Rotary 60,letted 9�Power Auger <br /> (in settion grid vith "X') Sketch map of well loca[ton <br /> y i 6. OBSTRULTIONS <br /> T ��tructed�Ye5 � No <br /> _ � _ ._ _. � " tons removed�Yes []No If obstructionz cannot be <br /> � � � � removed, contact MDH <br /> w - ` - - • - - -I- - E 9 <br /> beforc sealin . <br /> ' ' : : T �. �sE <br /> ' ' " y„�. 1�Domestic 4�Monitoring F�]Heat Loop <br /> _' <br /> ' � ' : I 20 irrlgation 50 Public 90 Industry <br /> ..�_ . .,. _ . j 3(]Test ?1ei1 b0 11uni�ipa] IC[�C�emercial <br /> �--1 SL � 1(]Mr Condttloning 1][] <br /> 2. PROD;RTT OWHER'S NAME Ma111ng Address if difterent than 8. CASIN6(5) <br /> F7� - /1 � � property address indicated above l�Black 4�Threeded 7(] <br /> 1��� �^'��� <br /> 2[]Galv. 5[]Melded <br /> ��^L 30 Plastic 6[]Stainless Steel <br /> HARDNESS OF _ � J �� ft. <br /> 3. FORHATION LOG COLOit FORMATION FROM TO 1n• to < <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> 9. SCREEN <br /> �Screened well from L��. Co�'+ft. <br /> (I� known) <br /> ' �Open Hole fron_ ft, to_ ft. <br /> 10. STATIC NATER LEVEL <br /> �y_ft. e below []above <br /> land surface Date Measured � - J I-c a <br /> 11. WELLHEAD CONPI.ETION <br /> 10 Pitless Adapter �Faund Buried <br /> 2�J Basement offset 50 <br /> 3�Mell Pit <br /> 16. REMARKS, ELEVATI011, SOURCE OF DATA - CASINGS REHOVED, CASINGS PERFORATED. ETC. <br /> 12. GROUTIN6 INFORMATION <br /> 1�Neat Cement 2�Bentonite � <br /> Grout materlal � from/�td�ft. cu. yds <br /> 13. NEAREST SOURCES OF CONTAMINATION /' � <br /> /L feet [�ti dtroction `�i2.�i�..-._ type <br /> Neil disinfected before sealing? e Yes <br /> 14. PUMP �Removed �Not Present <br /> Type: 1[1 Submersible �L.S. Turbine � Reciprocating <br /> 2�'Jet a0 Centrifugal 60 <br /> 15. EXIS7ING 4ElLS (Please sketch loc�ttons of abandoned and <br /> � activ� wells Tn remarks sectton or on back.) <br /> � Other unused w�ll(s) on propertyt �Yes � No <br /> Abandoned: � Permanent �Temporary �]Not sealed <br /> 17. WATER NELL CONTRACTORS CERTIFICATION <br /> This well was sealed under my jurisdiction and this reDort <br /> is [rue Co the best of my knowledge and belief. <br /> � L� .�L". �'L�t [r ! _ <br /> Licensee �siness Name � `, L1c se No� <br /> . .6...��� ! <br /> r' <br /> Address <br /> Signed _ � Cate - J `J� 7 <br /> � Z�, , Date �- > 7—� <br /> FFICIAL ABA11ppHED 41E11 RECORD (May be used for Property Transfer) 'Hame f Dr ler ✓ <br /> IJIPQIP.WSr P773 MZT& DSBD ' <br />