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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED NELL RECORD <br /> 1. LOCATfON OF MELI M(eaEe�tankNf�noE Wnown)NO. <br /> County Name <br /> Township Naaw Tornshtp umblr Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> Ly E 4 ti af 4 ^ <br /> D /7 5r �-3 � � — ;; / ! ft. �/ � <br /> v <br /> Numerical Street Address and Ctty of Well Location or Diztance from Road 5. DRILL G METHOD (1f known) <br /> _ Intersectton 1�Cabl� tool 4[J Reverse 7(]Drlven IQ]Dug <br /> 6 J J/ 2[]Hollow Rod 5[]A1r �]Bored 11[] <br /> C ;s� <br /> Show exact 1outlon of well <br /> 3�Rotary 6�Jetted 9�Power Auger <br /> � <br /> (tn sectton grtd rtth 'X') Sketch ayp of welt loutlon �' <br /> 6. OBSTRUCiIONS y� <br /> N Wel1 obstructed Q Tes ,(�r No ;� <br /> _ t _ _ _ ._ _. ODstructions removed 0 Yes �No If obstructlans eannot be � <br /> � � � ' reaaved, contact MDH � <br /> M - ' -• � -I- ` E before sealtnq. ,�, <br /> - -+ <br /> . : , � T � �. �sE ��. <br /> - - •-�'� y�,d. l�rn C�r.-•.,.,c .J P..�.�tortny �heat LooP •�c <br /> ! ' ' • ( 20 Irrlgallon 50 Publte 90 Industry !`�� <br /> ..�. . ._�.. _.,.. ._,. <br /> ' S ' 1 30 Test Well 60 Municlpal I[Q Comaeretal <br /> ►---1 .iL----� 7[]A1r CondTHoniny 11[] 'i" <br /> 2: PR RTY OWNER'S NAME Matltng Address if different than 8. CASIN6(S) �j� <br /> L�� Droperty address indtcated above 1�Black IQ Thre�ded 7C1 s;� <br /> ��.� <br /> zp c.i�. ,p w.ia.a ",;. <br /> � <br /> 3�Plastle 6�]Stainless Steel '� <br /> HARDNESS OF `< <br /> 3. FORMATION lOG COLOR FORMATION FROM TO ��^• to�tt. �; <br /> If not known, indicate formatlon log fron� new well or nearby wll, in. to ft. <br /> �t <br /> :'T <br /> 9. SCREEN <br /> �Scretned well fros_ ft. to_ft. <br /> (If known) <br /> �Open Nol� fron_ft. to_ ft. <br /> fp <br /> 10. STAT� MATER LEVEL !� <br /> _��� ft.Q below �abov� � , <br /> land surfac� Date Measured[{�/l�� ,. <br /> .'� <br /> I1. WELLHEAD COMP�ETIGN <br /> 10 Pltless Adapter �Found Buried ;�� <br /> 2�Basement offset '[} �«, <br /> 3�Hell Ptt <br /> 16. REMARKS, ELEYATIOM, SOURCE OF DAiA - CASINGS REHOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORM0.Ti0N <br /> I�Neat Cement 2[]Bentonite � <br /> � Grout material (��from�o_ ft. cu. yds <br /> _ _ � :;� <br /> 13. NEAREST SOURCES Of CON7AMiNA7I0N <br /> _ feet directton type <br /> � ' l <br /> D � , Hell dlsinfected beforc sealing? ,�Yes ; <br /> ���a`/ l=�- �Removed �Ylot Present � F <br /> 14. PUMP <br /> Type: 1[�Submersible �L.S. Turbine �Reclprocating <br /> 20 Jet a�Centrlfugal 60 '6^ <br /> � <br /> ��a� <br /> 15. EXISTING WELLS (Plessa sketch louttons of abandoned and ''" <br /> R Q� � � �J:i: active wells 1n remarks seeiion or on back,) "� <br /> Fi o Other unused w�l l(s) on property?„�'Yes � Bo c�`, <br /> Abandoned: �Permanent �Temporary �Not sealed "' <br /> :'� <br /> ;1- <br /> ll. MATER WELL CONTRACTORS CERTIFICATION �q <br /> This well was seeled under my ,�urisdictton and tMS reDort `� <br /> � is true the st of my knowled beltef. �-�a <br /> � ._ �j ' -- �� <br /> ,; <br /> ;.. <br /> L1cen �ys1n s �iF�K Llcense No. �r� <br /> C� �j -" 31 <br /> Address � � �:� <br /> r <br /> - Slgned � �� Date � � � �� <br /> 9 • � Oat� ! �' '� <br /> OFFICIAL ABANDONED VELL RECORD (May be used for ProDerty Transfer) � Name of Drtller ��"K� <br /> ZXPCgtTANT: 1�ZL8 IVITH DSBD <br />