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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO. <br /> (leave blank if not known) <br /> County Name Hennepin <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sea ed <br /> N E k 4of k r f <br /> Orono 117 or 23 yr 04 NE SE NW 3j L_f ft. -? d +6-1 <br /> Numerical Street Address and City of Well Location or Distance from Road 5. IL ING METHOD (if known) <br /> intersection 1 Cable tool 1[3 Reverse 7[]Driven 100 Dug <br /> 335 Old Crystal Bay Road Orono, Mn. . 20 Hollow Rod 50 Air BD Bored 110 <br /> 3D Rotary 60 Jetted 5Q Power Auger <br /> Show exact location of well <br /> (in section grid with 'X') Sketch map of well location <br /> 6. OBSTRUCTIONS <br /> M <br /> Well obstructed Yes No <br /> � Obstructions rNoved es 0 No If obstructions cannot be <br /> i removed, contact MON <br /> M - ' - -J( -I- ` - E I , )( l'4 before staling. <br /> , I � ► way <br /> T cV'f' (n 7.os(i <br /> '"'-- '' y mi -V 1 Domestic 40 Monitoring B0 Heat Loop <br /> L 20 Irrigation 5[J Public 90 Industry <br /> S A 30 Test Well 60 Municipal HIDCommercial <br /> 0---1 ori La--4 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than R. CASiNG(S) <br /> property address indicated above 10 Black Threaded 70 <br /> Mimi Ryerse Cleary Construction Galv. 50 Welded <br /> P.O. BOX 120 Long Lake, MN. 30 Plastic 60 Stainless Steel <br /> HARDNESS OF ) 80 <br /> 55356 e...4 ,n. to ft. <br /> 3. FORMATION LOG COLOR FORMATION FROM TO <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> Drift 0 84' 9. SCREEN <br /> ®Screened well from 8 0 ft. to 84 ft. <br /> (If known) <br /> 0 Open Hole from ft. to_ ft. <br /> 10. STATIC WATER LEVE <br /> ft, below 0 above 7 / / <br /> land u ce Date Measured / / ( 41 I <br /> 11. WELLHEAD COMPLETION ((( ff <br /> 10 Pltless Adapter 4:3 Found Buried <br /> 20 Basement offset 4] <br /> Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED. ETC. <br /> 12. G_ RO(1TING INFORMATION <br /> J�`p'(�Neat Cement (3 Bentonite 3[( <br /> Grout 2" Well Approx. 84' Deep Grout material fromto O ft. cu. yds <br /> 2 Bags Cement _ _ <br /> 4 Lbs. Bentonite 13. NEAREST SOURCES OF CONTAMINATION <br /> 2 Men, Labor, Rig and Cement Grout Pump ^ feet direction type <br /> Well disinfected before sealing? 0 Yes <br /> 14. PUMP 0 Removed 'Not Present <br /> I CITy OF Type: 10 Submersible 30 L.S. Turbine Reciprocating <br /> ORONo 20 Jet Centrifugal 60 <br /> 0 f ri 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks sec o or on back.) <br /> Other unused weil(s) on property? D Yes No <br /> Abandoned: 0 Permanent 0 Temporary 0 i s &led <br /> A U 2 2 17. WATER WELL CONTRACTORS CERTIFICATION <br /> 1991 This well was sealed under my Jurisdiction and this report <br /> 1 is true to the best of my knowledge and belief. <br /> DON STODOLA WELT, DRILLING CO. , INC. <br /> Licensee Business Name License No.2 7 1 72 <br /> Address 15306 Hwy. 7 Minnetonka, Mn. 55345 <br /> SignedDate 7-8-91 <br /> 7 Mark Sto ola Date 7-8-91 <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> IMPORTANT: PIM WITH MOLD <br /> . <br />