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STATE OF MINNESOTA•DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL. M(leave blank NIQUE f of knoLwn)NO. <br /> County Name <br /> Township Name TP n r Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> N 11 E k k of k <br /> © / 1 7 Sr 4-,74). 7 i 7 p ft. 7 --I— <br /> -7 '7 J <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) f <br /> Intersection 1[]Cable tool 40 Reverse 70 Driven 100 Dug <br /> 42 2 0 0 0 /,/ •, .1j ` <br /> ./ — <br /> Hollow Rod 8Q Bored Air 110 <br /> Show exact location of well <br /> 30 Rotary 60 Jetted 5Q Power Auger <br /> (in section grid with •X•) Sketch map of well location 6. OBSTRUCTIONS <br /> N <br /> li_:_Ti-14 Well obstructed 0 Yes ® No <br /> Obstructions removed 0 Yes 0 No If obstructions cannot be <br /> ' i ' removed, contact MOH <br /> M _ _ _ _,_ .. _I_ 1 _ E before sealing. <br /> : 1 : T v` 7. USE <br /> • .-' - 4,,,C, �,(:: *--.„,4.,......a/' laDomestic 40 Monitoring 80 Heat Loop <br /> 20 Irrigation 50 Public 90 Industry <br /> 30 Test Well 69 Municipal 159 Commercial <br /> 1---1 wiLv--•+ 1 70 Air Conditioning 110 <br /> 2. PROPERTY OWIER'S NAME Mail ng Address if different than 8. CASING(S) <br /> Tr property address indicated above 10 Black firThreaded 70 <br /> (444 <br /> 2®..Galy. 51:I Welded <br /> ;ti-10,/,/, ( . <br /> 30 Plastic 60 Stainless Steel <br /> HARDNESS OF in. to /o2 1— 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 /> • <br /> 9. SCREEN <br /> A•Screened well from /24-it. to.39ft. <br /> (If known) <br /> ,0-1.7y..„4. o 7 rQ ❑Open Hole from_ft. to_ ft. <br /> 10. STATIC NATER LEVEL <br /> I, O ft. apelow 0 above <br /> land surface Date Measured 7-- 3 7 O <br /> :,.." <br /> 11. WELLHEAD COMPLETION . <br /> 10 Pitless Adapter 40 Found Buried <br /> ' 2Q Basement offset CI <br /> Well Pit <br /> 16. REMARKS. ELEVATION. SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1g Neat Cement 20 Bentonite 30 <br /> Grout material J from/J4o(ft. cu. yds <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> r <br /> 2.z.4,feet L41 direction .7., type <br /> Well disinfected before sealing? g Yes <br /> 14. PUMP 0 Removed 1GT'Not Present <br /> Type: 19 Submersible i"30 L.S. Turbine 5J Reciprocating <br /> 20 Jet 40 Centrifugal 60 <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? Yes 0 No <br /> Abandoned: (s(Permanent 0 Tempora 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 /> Li Bushes me 4 License Ns. <br /> Address 41—..7o �r j ' -' Jed, '9",y (140 <br /> • Signed + ..a//17.0e Date ")- )14-4!/ <br /> Date 7- .7-f/ <br /> FFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of ri frr <br /> I1lPORrAHT: PILE WITH DEED <br />