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