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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED IiELL RECORD <br /> 1. LOCATiON OF MELL M(eaEfbTank Nf�noE k own)NO• .�v �- <br /> County Name <br /> Township H�me TownsM p NuaDer Ran9e Humber Sectton No. Fr�ctlon 1. MEIL ^EPTH (co�plK�d) Dat� sealed <br /> C�(�OY�U N E 4 k of y <br /> � . ,-.l 11� s� 2 3 W� 21 �=N�1 S � ,3� ft. �� I � � I I.� <br /> Numerical Street Address and C1ty of Mell Loca[ion or Dtstance from Ro�d 5. �iL}ING METHOD (if known) <br /> [ntersection 1�Cable tool 1[)R�vers� 7(]Driven 1C[1 Dug <br /> i-� <br /> Hollow Rod 5[�A1r �Bored 11[] <br /> d celsiar Minn. 5533 Rotary Jett�d PowrAuer <br /> Show exact locatton of welt n � � 9 <br /> (in section grid vlth `7(•) � , SkKch map ot well loutton <br /> N 6. OBSTRUCTIONS <br /> Mell obstructad�Y s (] No <br /> _ � - - - ._ _. Opstructtons n�ov�d�es []No If abstructlons cannot be <br /> ' � I rewv�d, cont�ct IIpH <br /> W _ • - ' + -I- - E � . �u, b�fon sullnq. <br /> _ _ � T 7. S <br /> �� . ._ _i y� �pom�stic �Monitoriny �Meat looD . <br /> _�_ .:. _ ; : I � ��� <br /> W� 2[]Irrigattan 50 Publte 9� lndustry <br /> 3�Test Ikll fi�Municlpal 1C�Coow�rclal <br /> S os� <br /> �--1 �wts ?I�Atr Condttlonin� 11� <br /> 2. PROPERTY OwXER'S NAME Ma511ng Address tf different than 8, A NG(S) <br /> property addr�ss indicated aCov� �Black �Thre�ded 7(] <br /> J� 7"\ <br /> 2[]fs�iv. 50 Widtd <br /> Eva Jacabs Same �]ri.:c�c �]st,��i�:: sc�.t <br /> HARONESS OF <br /> 3. FOqMATION LOG COLOR fOfUNT10N FROM TO 1n. to �� ft. <br /> If not known, lndicate formatton log fro� n� wll or n��rCy rall. 1n, to ft. <br /> Dr if t 0 130 9��s«..�.e ,,,.>> f,�,. I�6rs. w 1�(�re. <br /> (If known) <br /> �Op�n Nolt fro� ft, to ft. <br /> 10. STATI 4ATER LEYE <br /> _�__ft. b�tor �abov� <br /> land�c� Oate ►4asur�d I� �1 <br /> ll. 11ELlNEAD COMPLETIOM <br /> 10 P1tl�sf Adapt�r �Found Buri�d <br /> �2[]IBasewnt off=�t 50 <br /> 3fY1N11 P1t <br /> 16. RENARKS, EIEYATIOM, SOURCE OF DATA - CASiNGS REMOVEO, LASINfiS PERFORATED, ETC. �� <br /> 12. �TIN6 INFORIMTION <br /> G r ou t �" We 11 13 0 ' De e p "!" `�"e '��'"`°""' � <br /> I Z B3�S Cement Grout �ur1a1 iro��30to� tt. cu. yds <br /> 14 Lbs. Bentonite — — <br /> 2 M e n, L a�o r , R i g a n d C e me n t 13. NEA1tE5T SOURCES OF CONTAMIkATION <br /> Grout Pump — ''•� a,�•�t,�^ tyo• <br /> Wll dls/nf�etW b�ton su11ny1 Y�s <br /> 11. PUMP �pa�oved �Ilot Vns�nt <br /> Typ�:�SuO�ersiblt �L.S. Turbin� �R�ciproutiny <br /> �J�t �]CtnLMfuy�l 5(] <br /> �("'E�r r : .'�-'�';� 15. EXISTIN6 WELLS (Plus� skKch loutlons of abandon�d tnd <br /> �_� �ctiw w�lls 1n n�arks i�c 1on or on bak,) <br /> � ' Other unus I1(s) on prop�rty7 �Yes No <br /> ,,� � ADandoned: ier�an�nt �ie�por�ry � t e�l�d <br /> U. W1iER MELL COMTRACTORS CERTIFICATION <br /> Th1s w�)1 vNs s��l�d und�r my jurisdlction and this report <br /> 1s true to tM best of my knowledg� and belief. � <br /> Dan Stadala ' s WEll Drilling Co <br /> .�!'t IV e 4 � 1993 licens�� Busln�ss Na�e ��y��2 <br /> Addr�ss 1530 H _7 t a Minn. S 345 <br /> s,s�•a - o.a 12 15 9 <br /> Mar Stodo a o,�. 12 15 <br /> FFiCIAL ABAlIDpNED YELL IiECOilO (Iby b� us�d for Prop�rty Tr�nsf�r) Na�e at Or117�r <br /> Il(PCRSAll s lZL3 �Ta pd�p <br />