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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF IIELL MItJNESOTA UNIQUE WELL N0. <br /> (leave b'ank tf not known) <br /> County Name �j � � <br /> r y�, <br /> 7ownst�ip Name Township umber Range Number Section No. Fraction 4. WELL OEPTH (completed) Date sealed <br /> � E : : of ; <br /> �ir��� � r d ? dl / � I J "� ft. � '- �l ' � <br /> S J C'J � � o� <br /> �merical S[reet tiddresz and City of Well Location or �istance �-.�n Road 5. ORILLING METHOD (if known) <br /> IIntersection , i 10 Cablr tool 4[�Reverse 70 Driven 10[�Dug <br /> � � � �� '/�` w� r^ O 2� Hollow Rod 5[�Air 8�]Bored 110 <br /> iY� ��i` <br /> 30 Rotary 60 Jetted 9�Power Auger <br /> Show exact location of well <br /> (in settion grid wfth "X") SRetth map of well location 6. OBSTRUCTIONS <br /> , N {� . Well obstructed�Yes � No <br /> _ � _ _ _ ,_ _� �n t�� Obstructions removed�Yes �No If obstructions cannot be <br /> ' ' i y/1 removed, con[act MDH <br /> ' -I- - E ' ` before sealing. <br /> w - - - - � - - <br /> ` ; , ; j �. �sE <br /> - - • -- -- 4,� 1�Domestic 40 Monitoring 80 Heat Loop <br /> ; ; i ! � lNf� 20 Irrigation 50 Public 9� Industry <br /> 30 Test Well 6�Munictpal 1C(]Commercial <br /> I �-1 SL- --� i• ' ��t� —_ 7�Air Conditioning ii�. <br /> 2. PROPERTY 01JNER'S NAME Mailing Address if different than 8. CASING(S) � <br /> �,A � � property address indicated above l�Black 4�Threaded 7[] <br /> X�Ll <br /> � 2[�Galv. 5�Welded <br /> � 3�Plastic 60 Stainless Steel <br /> HARDNE55 OF �_� .2 � �J� ft. <br /> I 3. FORMATION lOG CDLOR FORMATION FROM TO tn. to <br /> IIf not knovn, indicate formation log from new well or nearby well. in. to ft. _ <br /> 9. SCREEN <br /> �Screened well from�,�. to�t. <br /> (I,` knoM�n) <br /> I ��'� ❑Open Hole from ft. to ft. <br /> t-- — — <br /> 30. STATIC WATER LEVEL <br /> ,� U ft.� below []above <br /> � land surface Date Measured ' ��' <br /> 11. WELLHEAD LOMPlETION <br /> 1(]Pitless Adapter 4�Found Buried <br /> 2[�BasemenY offset s� <br /> � 3[�Well Pit <br /> 16. REMARKS. ELEYATION, SOURCE OF DATA - CASINGS REMOVE�, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1�Neat Cement 2�Bentonite � <br /> Grout material 7� frortr�t/�to� ft. cu, yds <br /> I 13. NEAREST SOURCES OF CONTAMINATION � <br /> r�� feet �_ direction � -`., type <br /> uell disinfected before sealing? � Yes <br /> �{� O 14. PUMP �Removed �Not Present <br /> 0 �O�j Type: 1[� Submersible 3�L.S. Turbine ;� Reciprocating <br /> �\C� 2�Jet G�Centrifugal fi� <br /> \% <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> Q�� active wells in remarks section or on back.) <br /> � '"i�l��!�y Other unused well(z) on property? �Yes � No <br /> 2 Abandoned: �Permanent �Temporary �Not sealed <br /> ��� <br /> 17. WATER WELL CONTRALTORS CERTIFICATION <br /> This well was sealed under my jurisdittion and this report <br /> is true to the be�5t of my knowledge and belief. <br /> � . � � �l � J 7� 7 t0 <br /> i <br /> Llcensee Business Nam License No. <br /> �_ <br /> Address <br /> � Signed � Oate ��/� <br /> _ �/�--� Date - l-�J <br /> FFICIAI ABANDONED uELI RECOFD (May be used for ProDerty Transfer) Na�Ae of ril�ler <br /> I.�CY2TAIVT: PZLE WZTH DESD <br />