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. _ __ _ . _ _ . <br />� STATE OF i7INNESOTA DEPARTPIENT OF NEALTN � <br /> ABANDONED HELL RECORD <br /> 1. IOCATIOk OF YEL�. � MINNESOTA UNIQUE WELL NQ. �� <br /> Ccunty !Iame / ' (leave bTank 1f not known) <br /> �, o <br /> Townshlp Nane Toxn ip Xum� Range Number Section No. Fraction 4, NELL DEPTH (�eted) �ate sealed <br /> E +a kof ` y <br /> i <br /> ��-v`'^-'� // � s' � �d � �+� ft. ,� �,2 J . �l U <br /> kumerlcal St+tet Ad:ir�ss and Ctt� �� ' ' 'ocatton or tst ce from i.uad 5. DRILLING METHOD (if knorm) <br /> inter ctton / � � _ q <br /> �y��}'� -;;y%t�r��2� � 1�'J 4able tool 4�Reverse 7Q Oriven 1C�Dug <br /> O i1 .,,��,�. Cj / r� 2[]Hollow Rod 5[�Air Q[]8ored I1(] <br /> . vU v � [�'C., <br /> Shor xatt locatton of ,.t)1 <br /> 3�Rotary 6�Jetttd 9�J Posaa� Augsr <br /> (rn ectton grid with 'X') teh map of well loeation u. OBSTRUCTIONS <br /> , Mell obstructed�Yes � No <br /> _ � _ _ : ._ _a Obstructions rempved�Yes [�No If obstructions cannot be <br /> ' removed, contact MDH <br /> I }/ - ; - - ; - � -�- ; - E before seallnq. <br /> � T �. �sE <br /> _1 <br /> y�, I�Domestic 4�4onitoring �Heat loap <br /> __ _; _ ' : I 2[] Irrigation 5�Pu411c 9[� Industry <br /> 1 3�Test Mell 6�Nuntcipal 1C[�Comcarctal <br /> �---t .riL— 7[]Air Condttlontng 170 <br /> 2. PRGP'c3TY OdNER'S t81t:E Ma111ng AEdress tf difierent than 8. CASING(S) <br /> � � property addresz 1ndlcated above 1�Black 4�Threaded 7(� <br /> � ��/7�r�� 2�Galv. 5(]St6'Ided <br /> 3=]Plastic �Stainless Steei <br /> H.ihUIlESS OF <br /> 3. FORlVITTON L06 COLOR FOZMATION FROM TO 3 ��. to / �l�I ft. <br /> If not known, indtcate formation log fro�x new well o� nearby well, in. to ft. <br /> 9. SCREEN �--�1 <br /> �Screened we11 from �5'�. to%�t. <br /> (I' known) <br /> ' �Opcn Hole fron i ft. to� ft. <br /> 10. STA7IC YAiF�R LEYEI <br /> J ° ft. (�]betor ❑above <br /> land surface �ate Measured 7 -a-f' F"� <br /> 11. WELIHEAD COMPLETION <br /> 1�Pitl:ss Adapter �Found Buried <br /> 20 Basem^nt offset � <br /> 301:e11 Pit <br /> 16. REMARKS, EL::'iAfIOtl, SOURCE Of OATA - CASINGS REMOVED, CASINGS PERFOP.A'(ED, ETC. <br /> 12. GROUTING 1NFORNpTIOM <br /> 1�Neat Cement 2�Bentonite � <br /> � Grout material 6 from��o D ft. cu. yds <br /> I — <br /> I 13. NEAREST SOURCES OF CONTAqIlUTION r <br /> � � feet 4� direetion �- '�'�-- tY9� <br /> Well dlsinfected before seaiing? �Yes <br /> _ �-- �"��� 14. PUMP �Removed �Not Prcsent <br /> � Type: 1[�Submerslble �l..S. Turbine �Reciprocating <br /> (\ �. <br /> � �"'� Jet Centrifu al <br /> �����,� � � 9 sa <br /> I5. EXISTING AELLS (Pleass sketch locations of abandoned and <br /> active we11s in rcmarks sectton or on back.} <br /> Other unused wetl(s) on property7 �Yes �Mo <br /> Abandon._d: fJ Permanent �Temporary [�Not seated <br /> A�� 1 ��� 17. NATER WELL CONTRA�TORS CERTIFfCATI0t1 <br /> '• This well was sealed under my Jurisdiction and this report <br /> ._ is true to the best of my knowledge and belief, <br /> ����--�G _ � 717_�L/�__� <br /> Licensee Business Name // � Ltcense No I <br /> � d �-t <br /> � _ _ ; <br /> Addre55 <br /> � Signed Date � ,;,j. �� jr'�/ <br /> Date -+p�f�L <br /> FFICIAI ASANOONED �tEIL kECOR� (May be used for Properry Transfer) �Na of Driller <br /> ZXPCRTAIPT: PISB H7� DEBD <br />