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STATE OF MINNESOTA DEPARTMENT OF HEALTN <br /> ABANDONE� NELL RECORD <br /> 1. �oC�Tton aF uEu MINNESOTA UNIQUE WELL N0. <br /> County Name ,�` (leave blank if not known) <br /> i <br /> � `� / � <br /> Townzhip Hame Township umb�r Range Number Section No. Fraction 4. NELI DEPTH (tampleted �ate�sealed <br /> /:,l E k h o f y <br /> �Y > <br /> � � ft. j/ <br /> / or � —/ <br /> / �fsYi-c�— ( � s _� w>' --, ..S�' ..5.�„1 ��v U �' `-� <br /> Numerical Street Address and City of Mell Location or Oistance from Road 5. �RILLING METH00 (if known) C <br /> Intersectton � 1�Cable tooi 4�Reverse 7(]Driven 10[]Dug <br /> 3 � � � "' 2Q Hol low Rad 50 Air 8(]Bored 11� <br /> Show exact lotation of well 30 Rotary 60 Jetted 90 Power Auger <br /> (in sectton grld r1tA "X') Sketch map of well lotatlan <br /> N 6. OBSTRUCTIONS <br /> , Ne11 obstructed Q Yes �° No <br /> - � - - : •- -� Obstructlons removed�Yes �No If obstructions cannot be <br /> i � <br /> � removed, contact MOH <br /> M _ . _ _ . _I_ _ E before sealing. <br /> _ :_ � : � T �. �sE <br /> t � y..i. 1.�Domestlt 4n Monitarinn Af1 ue.t ���p <br /> ' , ' � 2�Irrigatton SQ Public 90 Zndustry <br /> •-�. . ._... _.i.. __.. <br /> � S � 30 Test Well 6❑Munitlpal lt0 Cortmercfal <br /> �---1 niL---i 7�A1r Condltloning 11[] <br /> 2.i�RT�R'S NAME Mailing Address 1f dtfferent than 8. CASING�S) <br /> � property addresz indicated above 1�Black 40 Threaded 7[] <br /> � 'i'��.L 2[�Galv. 5[�Melded <br /> 30 Plastic 60 Stalnless Steel <br /> HAR�NESS OF <br /> 3. FORMATION LOG COLOR FORMATION FROM TO � in, to��ft. <br /> If not known, lndicate formatlon log from new well or nearby well, 1n, to ft. <br /> 9. SCREEN <br /> �Screened well from_ ft. to ft. <br /> (If known) <br /> �Open Hole fram_ ft, to _ tt. <br /> 10. STATIC�LEVEL <br /> �_ft. � below �above y�//�y_ <br /> land surface Date Measured 5������" ( <br /> / <br /> 11. WELLHEAO COM�LETION <br /> 10 Pltless Adapter �Found Buried <br /> 2�'�Basement offset � <br /> 30 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASIN6S PERFORATE�, ETC. <br /> 12. GROUTING INFORW�TIOk <br /> 1�Neat Cement 2[]Bentonite � <br /> Grout material �f�,^.•-.,�_fro��to U ft. cu. ydz <br /> — __ — � <br /> 13. NEA$�$7 SOURCES E COIi7AMINATION n ' <br /> ,� feet � dlrectton `.�i/�{�f/�,Q type <br /> Metl dlsinfected before sealingt [] Yes <br /> 14. PUMP ,�Rertaved �Not Present <br /> Type: 1[� Submersible 3� l,S. Turbine � Reciprocating <br /> , 2�I Jet 40 Centrifugal 60 <br /> r <br /> 15. EXISTING WELLS (Please sketch locattans of abandoned and <br /> active wells tn remarks section or on 6ack.) <br /> . Other unused wall(s) an property? �Yes �''No <br /> - Abandoned: �Permanent �Temporary �Not sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> Th1s Hell was sealed under my ,jurisdlction and this report <br /> �} *,�..,;_;; is true o the be of �ny knowledge and eltef. <br /> ���Pa\� _ , _ `'�/ <br /> � .� <br /> Llcensee Bustness ame Ltcense No. <br /> Address <br /> SigneE�j� / Oate - <br /> ! � <br /> Date <br /> OFFICIAI ABANDONED WELL RELORO (May be used for Greperty Transfer) ame of Dr111er " <br /> IlIPC�TART; PZLS WZTE DSSD _ .-�� <br />