HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEAL7H
� ABANDONED NELL RECORD
i. �ocArcON oF �+Eu MINNESOTA UNIQUE WELL N0.
� (leave blxnk tf not known)
tounty Nav�e
Township Name Township mber Range Number Section No. Fraction 4. WELL DEPTlI (completed) Date sealed
V 1 '�1.�v W / ( �� � 3 r � k k of k� �� ft. �� r- 6� '- < �
("J
Yumerical S[reet Address and Ctty of Well Location or Distance from Road 5. DRILLIN6 METHOD (if known)
Ir,tersection 1[]Cabla tool 40 Reverse 7[�Oriven 10[�Dug
i �� O�` 2�Hollow Rod 5[�A1r 8[(Bored 110
3�Rotary 6[,]Jetted 9�Power Auger
SAow ezact location of weil
(tn zectton grid with "X") Sketch af tatton 6. OBSTRULTIONS
N Nell obstructed�Yes � No
_ � _ _ _ ._ _� ��v�J Obstructions rem�ved�Yes �No If obstructions cannot be
� � � removed, contact MON
' � � � � before senting.
►+ - ; - : -. -I- , - ��
. , � , � T �. �5E
' `' ' y 1�Domestic 4�Monitoring 8(]Heat Loop
•-h-- r_______________.._.
I
' ; _ ' ; � �7 2[�Irrigation 5[�Public 9r Industry
u J v 3[j Test Well 6�Munitipal lOL Commertial
$
r--1 „�U--� 10 Air Conditioning 11[]
2. PROPERTY OWNER'S NAyE M iting Address if different than 6. CASING(S) �
��avl� property address indTcated above 1�Black 4�Thr:aded 7[]
//� 2�j Galv. 5[J Welded
�� 3�Plastic 6�Statnless Steel �
HARDNESS OF � �n, to�_ft.
3. FORMATION LOG COLOR FORMAT(ON FROM TO
If not known, indicate formation log from new well or nearby wetl. 1n. to ft.
9. SCREEN
� �Screened welt from���ft. to�ft.
(If known)
�Open Hole from_ft. to_ ft.
~ cJ 10. STATI MATER LEYEL
' �ft. �below (]abave
land surface Date Measured .�—�- ��
11. 41ElLHEAD COMPLETION
10 Pitless Adapter 40 Found Buried
Z[f 8asement offset �
�41e11 Pit
16. REMARKS, EIEYATION, SOURCE OF DATA - CASINGS REMOYED, CASINGS PERFORATED, ETC.
12. GROUTING INFORMATION
� I�Neat Cement 20 Bentonite �
� Grout material � from�to� ft. cu. yds
13. NEAREST SOURCES OF CONTAMINATION
�C/ feet _�� direct/on " _type
D �� Well disinfected before sealing7 � Yes
��(� Q
�On,.,� 14. PUMP �Removed '�Not Present
L7 UL�
Type: 1[I Submerslble 3� L.S. Turbine � Reciprocating
2�Jet 40 Centrifugal 60
��� 15. EXISTiNG 41ELL5 (Please sketch locations of abandoned and
active y+ells in remarks section or on back.)
2 �9�� Other unused we11(s) on property7 �Yes � tla
� - , A6andoned: C1 Permanent �Temporary [�Hot sealed
17. WATER WELL CONTRACTORS CERTIFICATION
This well was Sealed under my jurisdiction and this report
is true to the b t of my knowledge and belief.
�_ .� c�� � � �
Llcense Buslness Name � ce se No.
Address
Signed �ate �� 7
Date "� '-�
FFICIAL ABANDONED 41ELL RECORO (May be used for �roperty 7ransfer) Name Dr1 er
IXPQRTAIVT: PILB p7TS DdSD