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STATE OF MINNESOTA•DEPNRTMENT OF HEALTH <br /> • <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL• MINNESOTA UNIQUE WELL NO. <br /> (leave blank if not known) <br /> • <br /> County Name <br /> i <br /> Ci1Tow,nnsshiippyNamee Towns p Num© Range ^Number Section No. Fraction h 4. WELL DEPTH�(completed) Date sealed <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) / J <br /> Intersection 1(]Cable tool 41:3 Reverse 70 Driven 100 Dug <br /> Q Vr/ l � y7! e Aiy c 213 Hollow Rod 5❑Air 80 Bored 110 <br /> 3❑Rotary 6❑Jetted 9❑Power Auger <br /> Show exact location of well <br /> (in section grid with "X") Sketch map of well location 6. OBSTRUCTIONS <br /> N -1,f Well obstructed Yes ❑ No <br /> gym=/ Obstructions removed Yes (]No If obstructions cannot be <br /> removed, contact MON <br /> -'. _ E before sealing. <br /> ( T 7. USE <br /> •• � - y.i. �/ 1KDomestic 40 Monitoring 80 Heat Loop <br /> 21:3 Irrigation 510 Public 90 Industry <br /> 3❑Test Well 6❑Municipal 1010 Commercial <br /> 1 Sit--+ Fe' <br /> J7❑Air Conditioning 11❑ <br /> 2. PROPERTY OWNER'S NAME Mailing Add different than 8. CASING(S) <br /> _ property address indicated above 1[]Black aThreaded 70 <br /> 7714fi <br /> Galy. 5E1Welded <br /> 31:3 Plastic 6❑Stainless Steel <br /> HARDNESS OF <br /> 01 in. to ) 1 V 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 /> 9. SCREEN <br /> Screened well from Loft. to,LO)t. <br /> (If known) <br /> 0 Open Hole from_ft. to_ ft. <br /> 6(2 .-Le. <br /> ( I V l 7,7" 10. STATIC}HATER LEVEL <br /> ft.ig,,Qe1ow ['above <br /> ,✓?J� <br /> land surface Date Measured / <br /> 11. WELLHEAD COMPLETION <br /> 10 Pitless Adapter 4❑Found Buried <br /> 2❑Basement offset 50 <br /> W11 Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1.Neat Cement 2❑Bentonite 3[] <br /> Grout material from���Oft. cu. yds <br /> 13. ' u <br /> NEAREST. SOURCES OF CONTAMINATION <br /> / Q <br /> � feet W direction type <br /> Well disinfected before sealing? Ayes <br /> 14. PUMP 423 Removed 0 Not Present <br /> Type: 1[)Submersible 3❑L.S. Turbine Reciprocating <br /> 254Jet 4❑Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks section or on back.) <br /> Other unused will(s) on property? I,4 Yes 0 No <br /> Abandoned: 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 /> LiclAsee Busin ss Name License No. <br /> Address C ,3o t <br /> boy <br /> Signed Mfr Date 7 <br /> �`�►.f�. •..�°.. Date 7--?--e/ <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of ,r,ler <br /> IMPORTANT: PILE HITS DEED <br />