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�l <br /> '� <br /> STATE OF MINNESOT.4 DEPARTMENT OF HEALTH <br /> ABANDONED NELL RECORD <br /> 's <br /> 1. LOCATION OF MELI MINNESOTA UNIpUE WELL N0. <br /> County Name (ieave blank 1f not known) 1•`y' <br /> ,_� <br /> TownsM p Name Towns D NumD r Range Number Section No. Fraction 4. WELL DEPTH (completed) Oate sealed ' <br /> � E 4 M ot y ; <br /> Q(�, / ` Sr � �{ � �� � ft. 7/�iJ. � <br /> % �yJ l � <br /> Numerical Street Addresi and C1ty af Wetl Locatton ar 0lstance from Road 5. DRIILING METHOD (1f known) <br /> Intersec N on 1�Cabte tool 4�Reverse 7[]Drlven 1�Oug ,i,': <br /> YD� 20 Hol law Rod 5[�A1r �]Bored 11[] <br /> Show exact toc�tion ot well <br /> 30 Rotary 6Q Jetted 90 Power Auger <br /> (in sectton grid rlih 'X') Sketcb map of well lotatton 6. OBSTRUCTIONS ' <br /> N , well ob:tructea p res�] no <br /> _ � _ ._ _. ODstructlons removed�Yes �No If obstruetions cannot be <br /> � � � naaved, contact MOH z <br /> W - _ -•- -I- E beforc sealtny. <br /> _ . <br /> . : : _ T • �. �sE <br /> " ' y R, • �Domestic 4�Monttortng �Neet loop <br /> �_ , ' F�'j irr;gatton a�7uoitc �Industry <br /> t • � '��J � 30 Test M�ll 6=]Muntclpal 1C0 Commercial <br /> r--1 SL 7[]Air Condltloning 11Q <br /> 2. P RTY OWNER'S NAME Ma111ng Address if different than 8. CASIN6(5) <br /> property address 1ndlcated above 1�Black 4�Threaded 7[] <br /> '� n C—_ 2[]Galv. 50 Welded <br /> / <br /> ��.� 30 Plastic �]Stainless Steel <br /> HARONESS OF '� 1n, to�ft. <br /> 3. FORMATION lOG COLOR FORlNTION fROM TO <br /> If not known, tndicate formatton log fron� new we11 or nearby well. 1n. to ft. <br /> 9. SLREEN <br /> �Screened well from_ft. to_ft. '' <br /> (I! known) -;�� <br /> �Open Hol� fron_ ft. to_ ft. -Y <br /> 10. STATIf�UV(ATE�t IEVEL ti <br /> I U tt. Q below �abov� ,. <br /> l�nd surface Date Meesured_� �� <br /> 11. WELLHEAD COMPLETION �;� <br /> 1�Pitless Adapter �Found Burled +; <br /> � <br /> 2�Basement offset '� �� <br /> 30 Hell P1t � <br /> 16. REMARKS. ELEVATIOB. SOURLE OF OATA - CASIN6S REMOVED, CASiNGS PERFORATED, ETC. �,��. <br /> 12. GROUTING lNFOR141TION <br /> I�Neat Cement 2�Bmtanite � <br /> " Grout materlal �p�2r/_.�.�7`7rom�to�ft. cu, yds ;; <br /> ;.i <br /> — — —i <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> _ feet dtroction type ;� <br /> Hell dtsinfected Detorc sealingt �Yes � <br /> 14. PUMP �Removed �Not Present � <br /> � �� j j Typr. 1[1 Submersible � L.S. TurClne �Reclprocating .��'� <br /> ����� �' 2�`Jet a0 Centrifugal 60 �, <br /> � � <br /> 15. EXISTING WELLS (Pleas� sketch louttons of abandoned'and ;� <br /> activ� we11s 1n remarks section or on back.) <br /> Other unused w�ll(s) on propertyT �^Yes � No � <br /> + <br /> ADandoned: �ermanent �Temporary �Not sealed <br /> �F R � � 1�.�1 v� 17. MATER WELL COBTRACTORS CERTIFICATION , <br /> This rrell was sealed under my �urisdlttion and th15 report <br /> Ts tru to the b t of my knowledge and beltef. <br /> ,`� <br /> z vl�� �� <br /> Licensee�Buslness t/ame Llcense No. ..� <br /> • � <br /> ' � ii <br /> Address <br /> � � <br /> - $igned ~ e l "� <br /> � Dat� :� <br /> OFFiCIAL ABANOONED MELL RECORO (May b� used far CroD�rty Transfer) Rame of Ortil�r ,.,i <br /> IXPLBtTANT z lZLS �rIT9 DBBD <br />