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STATE OF MINNESOTA DEPARTFIENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF �ELL MINNESOTA UNIQUE WELL N0. <br /> Coun[y Name (leave blank if not known) H 8 1 2 1 1 <br /> Henne in <br /> Tovns�ip Hame To�nsnip NumOer Range NumDer Section No. Fraction 4. MELL DEPTH (completed) D�te sealed <br /> N E k y of y <br /> Orono 117N s� 23W w� 20 SE SW NW 113 "' 2/5/93 i <br /> Numerital Street AdOress and Lity of 41e11 locatian or Dlstance from Road 5. ORILLING METHOU (1f known) I <br /> Incersectian 1�Cable tool 4�Reverse 7[]Oriven 1�Dug I <br /> 2745 Ethel Avenue Orono, MN 55391 z�Ho„o„ Rod SpA,r �gartd ��p � <br /> Shor exact locatlon of well <br /> 3�Rotary 60 Jetted �Powr Auger <br /> (in sec[ion grid rith "X") Sketcn map of welt locatfan <br /> M 6. OBSTRUCT(OMS <br /> , Helt obstructed Q Yes � No <br /> - � - - - -- -� - Obstructtons reiwved�Tes �No If obstructtons cannot Ce <br /> _ f <br /> i <br /> renoved, contact MOH <br /> 11 - -X - • - . -I- . - E before saling. <br /> . : : : � T �. �sE <br /> y.(. 1�]Domesttc q�Mpnitoring �Heat Loop I <br /> ,;. _;, _ ; _'._ I 2j] Irrigatton �PuDitt � Industry I <br /> I <br /> 1 30 Test Well 60 MuniNp�l 1��oa�e��i�� i <br /> '-'--1 SL 1�Mr Canditionfny 110 <br /> 2. P R O P E R T Y O W N E R'S N A M E M a i l tnq A d dress 1 f d ifferent than 8. CASING(5) <br /> property address indlcated above 10 Black 40 Threaded ](] <br /> Ben Jensen �w�� �w��a�d I <br /> 30 Ptasttc 60 Statnless Ste�l I <br /> HARDNESS OF 2 <br /> 3. FOfUlATION lOG COLOR FONMATION FROM TO �^• �� «• <br /> If not known, indicate formatton log frou new well or nearoy well. 1n, to ft. <br /> 9. SLREEN <br /> �Screened w�ll frw_ ft. W ft. <br /> - (If known) <br /> �Open Hol� fro�_ ft. to_ ft. <br /> 10. STATIC44�TER LEVEL <br /> ft. [1l]belor �aDove <br /> l�nd zurface Oate lkasured 2/5/9 3 <br /> 11. 4ELLHEAD COlIPlETION <br /> 1� Pltless Adapter �Faund Buried <br /> 2[� Basement offsat � i <br /> 30 Well Pit � <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVEO, CASINGS PERFORATED, ETC. j <br /> 12. GROUTfNG INFOti1MTI0N i <br /> 1�Neat Cenent 2[]Bentonit� � � <br /> House has been sold. �r��� �__�1�, 2� b�y� �ro. � �olZ?�L. ��. yaS•�g <br /> — � <br /> 13. NEAREST SOURCES OF CONTAMIM1lTI0M <br /> _ feet direction �YD� <br /> Hell dlsinfect�d 6efon salingt � Yes <br /> 14. PUMP �Reroved �Not Dresent <br /> TyDe: 1[1 Subarslbl� ��,5. TurOine �Reciprocating <br /> 2�Jet �Centrifugal fi0 <br /> 15. EXISTING WELLS (Pl�as� sk�tcA locatlons of abandoned �nd <br /> activf `+ells fn rt�arks sectlon or on back.) <br /> Ot�er unuzed wll(s) on prop�rtyt �Yes �No <br /> Abandoned: C1 Persa�ent �Te�porary �Not sealed <br /> 17. WATER 4ElL CONTRACTORS CERTIFIGTION --~ <br /> This well w�s sealed under my ,jurizdiction and this report <br /> is true to the best af my knorledge and 6elief, <br /> Stevens Well Drilling Co. 27194 <br /> Llcensq�„gy�f�pqW N�ee2 W. Ltcense No. <br /> bc�+u i�i 1 <br /> Addrtsi Ma 1 e P1 ' MN 55359 <br /> Stgned �� Date 2/8/9 3 <br /> Tom Stevens u,t. 2/8/9 <br /> FFiCIAI ABANpOMEO YELL QECORD (May bt us�d for Proptrty Transfer) Naw of Dr111�r <br /> I1IPQtT iBT: PZLd iIZTH DdBD <br />