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ST'l�TE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> � 1. LOCATIOX OF WELL MINNESOTA UNIQUE wELL N0. �j� � ' <br /> „ (leave blank tf not known) � <br /> ICounty 9ame ��^ n✓�� <br /> I 'ovnship Hame Townshi NumDer Rangc NumDer Section No. Fraction 4. WELI. �EPTH (completed) Date sealed <br /> ry E ; 4 of y <br /> I G�I,�F?�1/�rl� / � 1 Sr �%J Nr '� � ��� ft. � '�/�C/ I L <br /> / <br /> NURer cal Street Address ana City of Well Location or Distance from Road 5. ORILLING METH00 (if known) <br /> I Incersec:ion 1�Cnble tool 4[J Reverse 7(]Driven 1C�Dug <br /> I L _/ (�� /' 20 Hol lav Rod 5[�Air 8[]Bored 110 <br /> �_ / � � �� �/ ��-tiZ"'"G" �C.L?' r <br /> �—--� 3� Rotary 60,)etted 90 Power Auger <br /> iShow exact lecat!on of well ✓ I <br /> (in zection grid ri[h "X") /�,, Sketch mnp of well location 6. OBSTRUCTIONS <br /> M � Well obstructed�Yes � No <br /> _ � _ _ ; _ , �� / Obstructlons removed�Yes [�No If obstructions caanot be <br /> _I._. _ <br /> I i l,C-��� removed, contact MDH <br /> � _ ' � _ ���� before sealing. <br /> -I- - E <br /> , . , . <br /> � _ L _i : , , , r � � .� � �. �sE <br /> - l / I�Domestic 40 Monitaring 80 Heat loop <br /> ! i_- �..' y��. _�_�j Z� ;rr;ya.�„�� �:uoiic '� lnaustry I <br /> �I i I I 3�Test Nel l 60 Munit1021 1�Comwrcial i <br /> � SL— 7�Atr Conditioning :1Q <br /> � <br /> ', 2. PP.OPFRiY OLINER'S NAME Mailing Address if different than 8. CASING(S) <br /> ' �_/���L�- Droperty address i icated above t� I(� Btack 4�Threaded 7(] � � <br /> �i f / ;��L'"L L " <br /> i C` � L7 n 'r �''� 2[�Galv. 5[]Welded <br /> �� ) �,�-• �' <br /> `��v ��'��� �' ���/�- S � � Y-�� 3[�Ptastic 60 Stainless Steel � <br /> I HARDNESS OF ) in. to J •J ft. <br /> ' . fORMAT:QY LOG COLOR FORMATION FRON TO <br /> � .. not kaowr�, indieate formation log �rom new well or nearby well. 1n, to ft. I <br /> ; 9. SCREEN <br /> L_ �Screened wel l from%'rft. to �<2�f*.. <br /> J (I` knexn) <br /> � � I LJ � G'G� �Open Hole from� ft. b � ft. I <br /> I10. STATIC NATER LEVEL <br /> I 7� ft. � below �above <br /> land surface Date Mensured �-� `�� �Il <br /> I I 11. WELLHEAD COMPlETION I <br /> � 1� P1Uess Adapter a�Faund Buried � <br /> 20 Basement offset 5� � <br /> t <br /> 30 Well P1t i <br /> 116. REFVRKS, ELEYATiON, SOURCE OF OATA - CASINGS REMO4E�. CASINGS PERFORATEO, ETC. I <br /> 12. GROUTING INFORMI;iION � <br /> 1[�i Neat Cement 2�Bentonite � i <br /> . r^_.� ._._�..� �, '_/ J� ._. .'� j�,� <br /> � - _, <br /> 13. NEAREST SOURCES Of CONTAMINATION /l <br /> / L,; feet �_ direction ,-�Sd'•—f�n�-�_ type <br /> Well dlsinfected before sealing7 � Yes <br /> I <br /> � <br /> 14. PUMP �Removed �Nat Present I <br /> I <br /> � __ . ' Type: 1[l Submersible � L.S. TurEine � Reciprocating <br /> � � 2�Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and i <br /> � attive wellt in remarks sectlon or on back.) <br /> '; Other unused well(s) an prooerty7 �Yes .�No i <br /> Abandoned: [� Permanent �Temporary �Not sealed <br /> i � <br /> i7. uATER WEIL CONTRA.CTORS CERTIFICATION i <br /> Z1�'.C�. This well was sealed under my jurisdiction and this repurt <br /> � ,APR <br /> �'°'jJy, is [rue tu the bes[ of my knowledge and belief. i <br /> ; �c �_ f;`;��� � <br /> , � �� � i <br /> � � U r.ensee Business Name „ Ltcense No. <br /> � � <br /> � � .(' 7 C� -�L'- % <br /> Address ?✓27ic--< ---�- <br /> Signed �L;�L,�-����'�-t_,L.�C�. �ate 1 1 -/j' <br /> � �4- ���s.- Date �� ' �� f L <br /> �FFICtAI aBANDOHEO V�ELL RECORD (May be used far Property Transfer) � ame of Dr117er <br /> ` Z1�pRTANTt PILS SeRTH D%SD <br />