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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABA(VDONED WELL RECORD <br /> i. �oc�TroM ov uEu , _' "I�INNESOTA UNIQUE WELL N0. <br /> ( (leave blank if not known) <br /> County Name ��,� �� �' � i I . <br /> Tovnsnip Name Tovnshi Number Range Number Section N� Fractian 4, d6L UEPTH (completed) Date sealed, <br /> ' � E k 4 of k <br /> � � I J l � .:� j or . �� ft. � _� j. <br /> ' %��; „-._;, _ ' a� � <br /> , is � <br /> iNumerical Street Address and City of '�ell Location or Distance from Road �S. GRIILING METHOD (if knoxn) <br /> Intersection ,C�able tool 4[]Reverse 7(��riven 10�Dug <br /> � { �/� / �'2�,���� //� , J� � �`L+ � � "FToliow Rod 5[�Air 8[]Bored 11[] <br /> / l <� <br /> Show exact location of well 30 Ratary 60 Jetted 9�Power Auger <br /> (fn section grid �ith "X") / Sketch map of well location 6. OBSTRUCTIONS <br /> N �N ' Nell obstructed�Yes � No <br /> _ � _ : _ ,_ _� � Obstructions removed�Yes [J No If obstructions cannot De <br /> � • i � �� � removed, contact NOH <br /> � � ' ' before sealing. <br /> ►+ - - - - • - - - -I- - E <br /> i o <br /> _ : : , ; T v�y � �. �sE <br /> •- • • - -- y� � l�f Domestic 40 Monitoring 8[]Heat Loop <br /> • . y� 4 2C1 Irrigat1on 5�Public 9� lndustry <br /> ' � � � i -�—�- S iC � ,iLJ iest Mel7 oU Nunicipai lC[�J Comrkrctal <br /> �1 S�_ I � 70 Air Conditioning 11�] <br /> 2. PROPERT�Y ONNER'S NAME Maiting Address 1f different than 8. CASING(S) <br /> (;w_��� property address indtcated above 1[]dlatk 4[�r]Threaded 7[] <br /> /' p/ / 2�Ga 1 v. 5Q We 1 ded <br /> !% �- <br /> V ��� ��'�^'✓" w 3L]Plastic 6(]Stainless Steel <br /> HARDNESS OF /��f"-- {t• <br /> 3. FORlfATION LOG COLOR FOKMATION FROM TO '1- �n. to_j2= <br /> If not known, indicate formation log from new well or nearby well. 1n. ta ft. <br /> I 9. SLREEN — <br /> � .�Screened wel l from��t, to ?V ft. <br /> r-- (If known) <br /> _ 7--- � � �-' ❑Open Hole from_ft. to_ ft. <br /> 10. STATIC WATER LEVEL <br /> �-� ft. �below []above I <br /> land surface Date Measured � -�� ? <br /> 11. 41ELLNEAD COMPLETION <br /> 1(]Vltless Adapter 40 Found Buried <br /> 2f�Basement offset � <br /> 3(]uell Pit <br /> I16. REMARKS. E�EVATION, SOURCE OF DATA - CASINGS REHOVED, CASINGS PERFORATED, ETC. <br /> I 12. GROUTING INFORMATION <br /> � l�v-Neat Lement 2�Bentonite � <br /> iGrout material � �zfrom�':to Qft. cu. yds <br /> I — — --� <br /> 13. HEARE57 SOURCES OF LONTANINATION ��/ <br /> ' 1�feet (.�✓ dlrectlon C�'Z.y�-�-� type <br /> '�elt disirtfected before sealingt (�Yes <br /> I <br /> 14. PUMP �Removed � Not Present <br /> Type: 1[�Submersible 30 L.S. Turbine � Reciprocating <br /> � �Jet 40 Centrifugal 60 <br /> 15. EX(STING WELlS (Please sketch locationz of abandoned and <br /> active wells in remarks section or on back.) <br /> Other unused well(s) on property7 �Yes � No <br /> Abandoned: [] Permanent �Temporary �Not sealed <br /> 17. NATER NELL CONTRACTORS !:ER7IFICATIOM <br /> TM s well was sealed ,:nder my jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> - - ��� � 1� � �d� L <br /> ltcensee Busin�s Name �Y,License No. _ <br /> L , <br /> Addre55 '�'L ^ '�-� <br /> Signed i � _� Date C ' / `'9 � <br /> �----�--�- G't-- Date �� �� �- <br /> iFTCIAL ABANpOHED MELL RECORD (May be used for ProDerty Transfer) � e of �riller . � <br /> IXPp2TAA1T; PZLA KITH DSSD . <br />