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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO. <br /> County Name Hennepin (leave blank if not known) 2 1 5 1 6 <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Data sealed <br /> N E k k of 4 <br /> or or ft. <br /> Orono 118N S 23W W 33 SE NE SW 126 07/10/92 <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) <br /> Intersection 10 Cable tool 40 Reverse 70 Driven 10(]Dug <br /> 245 North Old Crystal Bay Road Orono 20 Hollow Rod 50 Air BD Bored 110 <br /> Show exact location of well 30 Rotary 60 Jetted 90 Power Auger <br /> (in section grid with 'X') 55356 <br /> Sketch map of well location <br /> N 6. OBSTRUCTIONS <br /> Well obstructed 0 Yes ® No <br /> - u - - - -- Obstructions removed(]Yes [3 No If obstructions cannot be <br /> removed, contact MON <br /> W _ _ _ . _I- . _ E before sealing. <br /> T 7. USE <br /> y.R. 'AA DO-5 c 40 Monitoring 60 heat Loup <br /> _ 1 20 Irrigation 50 Public 90 Industry <br /> 30 Test Well 60 Municipal 100 Commercial <br /> 1 <br /> La--------- 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than 8. CASINGS) <br /> property address indicated above 10 Black 4n Threaded 70 <br /> Tom Aldrich 2W Gal v. U Welded <br /> 3r3 Plastic 60 Stainless Steel <br /> HARDNESS OF 2 <br /> 3. FORMATION LOG COLOR FORMATION FROM TO in. to ft. <br /> If not known, indicate formation log from new well or nearby well, in. to ft. <br /> 9. SCREEN <br /> ®Screened well from_ ft. to ft. <br /> (I` known) <br /> 0 Open Hole from_ ft. to s ft. <br /> 10. STATIC WATER LEVEL <br /> 4 7 ft.E:] below 0 above <br /> land surface Date Measured 07/10/92 <br /> 11. WELLHEAD COMPLETION <br /> 10 Pitless Adapter 40 Found Buried <br /> 2® Basement offset <br /> 30 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> I®Neat Cement 20 Bentonite 30 <br /> .•ro.,. »�.a�iei 21e bati from to-T-7�tt. cu. yds <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> feet direction type <br /> Well disinfected before sealing? ® Yes <br /> 14. PUMP ®Removed 0 Not Present <br /> Type: 10 Submersible 30 L.S. Turbine 50 Reciprocating <br /> 20 Jet 40 Centrifugal 6[] <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks section or on back.) <br /> Other unused well(s) on property? 0 Yes ® No <br /> Abandoned: 0 Permanent 0 Temporary 0 Not sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was sealed under my jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> Stevens Well Drilling Co. , Inc. 27194 <br /> 624U'11'1gnway'IT West License No. <br /> Address Maple Pla , MN 55359 <br /> Signed 1 (At... (._._.— oate 07/14/92 <br /> Joe Stevens & Jeff DaCe 07707-9-7 <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> IMBCiRTAET: FILE KITH DEED <br />