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STATE OF MIN"�SO7A DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD � <br /> i. �oc�rton av uE�� MINNESOTA UNIQUE WELL N0. <br /> (leave blank 1f not known) <br /> County Name �� <br /> Tornship Name Township Number Range Number Section No. Fraction 4, uELL DEPTH (complete!j Date sealed <br /> 16� E k k of 4 <br /> �lr/�_ / �-� �s �� � � / �C, rt. ! +� " 3 / — ' / <br /> C= <br /> Numerital Street Address and City of Well Location or Distance from Road 5. DRIILING METHOD•(if known) <br /> Incersection I�Cabte tool 40 Reverse 7[]�riven lOQ Oug <br /> � � o � _�t��'��� lilic-✓v % �Hollow Rod 5�A{� �Bored 11(] <br /> 3�Rotary 6�Jetted 9�Power Auger <br /> Show exact location af wetl <br /> (in sectton grid vlth "X") Sketch map of well location � 6. OBSTRUCTIQNS <br /> N Well obstructed�Yes � No � <br /> _ � _ _ _ _ ._ _� Obstructlons removed�Yes �No If obstructions cannat be <br /> � � � removed, contact NOH <br /> W - ' - - ' - y -I- ` - E � before sealiny. <br /> J <br /> - _ :_ : :_ _� T �� �' '. °SE <br /> ;� yl.�. <br /> � � 1�Domestic 4�Monitoring 8�Heat Loop <br /> 2i] Irrigation �]Pubitc S[] Industry <br /> �..�_ `1l� <br /> ' ' ' 1 ! "J 30 Test Well 60 Municipal 1C(]Commercial <br /> � 1 SL 7�Air Condltianing 110 <br /> Z. .'ROPERTY OWNER'S NAME Mailing Address if different than 8. CASING(5) <br /> j I Droperty address indicated above 1�Black 4(�Threaded 7(� <br /> .� , <br /> `� �r� ,Jfi1���.�-.,,..%'L � 2�Galv. 50 Welded <br /> � 3I]Plastic 6j]Stainless Steel <br /> HARONESS OF ,� 1n. to � � ft. <br /> I 3. FORHATION lOG COLOR FORMATION FROM TO <br /> if not known, indicate farmation log from new well or nearby well. 1n. to ft. <br /> 9. SCREEN <br /> (,a'Screened r+ell from 7 J ft. to�(�t. <br /> �7 P (I° known) <br /> L� �7 � �Open Hole from_ ft. to_ ft. <br /> i 10. STATIL TER LEVEL <br /> ���ft.� below �above <br /> land surface Date Measured �v '3�- <br /> 11. WELLHEAD COMPLETIOH <br /> 10 Pitless Adapter 40 Faund Buried <br /> 2�BasemenL offset � <br /> 30 Nell Ptt <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROU??NG INFORMATION I <br /> �Neat Cement 2(�Bentonite � <br /> Grout material ,3 from�to (�ft. cu. yds� <br /> ! � 13. NEAREST SOURCES Of CONTAMINATION �. <br /> _LDfeet i...� directlon f��+-�— type <br /> { Mell disinfected before sealing7 �Yes <br /> 1 <br /> .�A N � �v"� 14. PUMP �Removed � Not Present <br /> Type: 1[1 Submersible 30 L.S. Turbine �Reciprocating <br /> ( i 2�Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks zection or on back.) <br /> Other unused well(s) on property7 �Yes �No <br /> Abandoned: C1 Permanent �Temporary �Not zealed <br /> I 17. 'dRTER WELL CONTRACTOR5 CERT(FICATION <br /> This well was sealed under my jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> t � �i�-(� / „�7� � �/ � <br /> LiceCsee�uslnes�Name ` `��ice��No. <br /> - Address '�y�L--- • �----. � <br /> J• ' � <br /> Signed _L� - �, . - -� �ate I 1 - 3 / <br /> i <br /> �L/t--� • �ate �J /- "r'7 <br /> FFTCIAt. ABArippXEO 'afLl RECORD (May be used for Property Transfer) �ame of D ilit , <br /> Zl'yL'CRT.l1172r F.TLS WZTII DSBU I <br />