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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED NELL RECORD <br /> i. �otATton ov uE�� MINNESOTA UNIQUE WELL N0. � f <br /> I County Name .�� (leave blank 1f not known) ;J � � � J <br /> I 'ovnship na e Tovnsni Numoer Range Number Section No. Fraction a. WELL OEPTH (completed) Date seated <br /> � ry E ; k of , <br /> / or / <br /> !��i/�i�— l l � Sr � .� W 7 � `r) ft. �� /`//L I <br /> li <br /> � 4umericai Street Address ane City of Vell location or Distance from Road 5. DRILLING METHOD (if known) I <br /> i :ntersection 1�Cablc tool 40 Reverse 7[]Driven 10(�Dug <br /> I L/� � / /�,c ��j��T %,' j��i/ 2[]Hol low Rod 5[]Air 8�]Bored 110 <br /> c� tv --t�> /• X <br /> I Shov eznct location of well <br /> 30 Rotary 60 Jetted 90 Dower Auger <br /> (in seccion griC vit� "X") Sketch map of well location 6. OBSTRUCTIONS <br /> � � / �/ ��'��� Nell obstructed�Yes � No <br /> I —� <br /> _ � _ _ _ _ � " Obstructions removed�Yes �No If obstructions cannot tre <br /> I ' -I ` � removed, con[act MOH <br /> � y ' ' 'I" _ ' -�- ` - E before sealing. <br /> il ' � � ' <br /> i . � . . � _ T I ���� � 7. USE <br /> i ; '( ' S .,,:, i 1}A,�Jomestic 40 Monitoring 8�Heat .00p <br /> _ _ , ^'�� I .__._—� 2� Irrigation 5�Public 9� Industry I <br /> � � � � 3�Test Well fi0 Municipal lC0 Comnercial i <br /> $ <br /> : .iL 70 Air Conditioning 11� i <br /> ' 2. ?ROPERTY puNEfi'S NAME Mailing Address if different than 8. CASING(S) <br /> ; �„Z�,�`,.�,J` proDerty address indifated above 1�Black 40 Threaded 7[] � <br /> � � yG U f- ���_ ��- . i <br /> 2[�Galv. 50 Melded � <br /> � �-�� '7��� J-� 3 `l f— Jr]Plastfc 60 Statnless Steel � <br /> � HARDNESS OF I <br /> 1n. to � -� ft. <br /> j 3. FORMATION LOG COLOR FORMATION FROM TO I <br /> I If not known, indicate formation log from new well or nearby well. 1n. to ft. I� <br /> I <br /> , 9. SCREEN �7 I <br /> �Screened well from L J ft, to/ � ft. <br /> � ^ r' (If know�) <br /> �.+ � V ❑Open Hole from_ ft. to _ ft. � <br /> 10. STATI WATER LEVEL � <br /> i ft. Q below �above ��• I <br /> � { land surface Date Measured �� � �� � �-� <br /> I � � <br /> 11. WELLHEAU COMPLETION I <br /> I IQ Pltless Adapter CQ Faund Buried <br /> ��, � 2�Basemen; offset � i <br /> � 30 Well Pit � <br /> �16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REROYED, CASINGS PEkFORATE�, ETC. i <br /> , 12. GROUTiNG INFORlIATION i <br /> 1�Neat Cement 2[]Bentonite � <br /> ���,� Grout material from�to�ft. cu. yds� <br /> — — —� <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> � feet �_ dlrectlon •-LL�c�.—. type <br /> � , <br /> j Mell disinfected before sealing? ,� Yes <br /> I <br /> 14. PUMP f,7lRemoved � Not 7resent <br /> Y <br /> Type: 1� Submersible � L.S. Turbine � Reciprocating <br /> __,_ _ ---- � ""�`� d�Jet 4�Cenirifugal 60 <br /> r- <br /> � 3 � <br /> I ` � 15. EXISTING WELIS (Ptease sketth locatlons of abandoned and <br /> ac:ive wetls in remarks section or on back.) <br /> I , _,�_ Other unused well(s) on property? �Yes (�j Na <br /> Abandoned: �Permanent �Temporary �Not senled <br /> ].7. WATER WELL CONTRACTORS CER7IFICATION � <br /> This well Was sealed under my jurisdlction and this report <br /> I is [rue to Che best of my knowledge and belief. <br /> APR 2 �.9�3 �_' C=J`� �.���1�? ,� 1:; � � <br /> Ucensee 9usiness Name License Na. <br /> I L �' � , ��-..�', ,� .l. <br /> Addre55 �'T�L i�a " -��- �� <br /> Signed � � __,._I�'� � Oate /L •( �f�L <br /> � ' n <br /> _ � `�ft-��,J�-�-� Date i,� �6 Jf <br /> �FFICIAI ABAIIDONED �ELL RECORO (May bt used for Property Transfer} �� of Drtller <br /> + II�CRTANT: lZLB G7TH DBSD <br />