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STATE OF MINNESOTA DEPARTMENT OF HFJILTH <br /> ABAN�NED WELL RECORD <br /> 1. LOCATION OF NEL • M(eaEe blank NtaeoE W^own)NO. <br /> ' County Name <br /> Townshfp Name To+mzhip Nwaber Range Number Section No. Frattion 4. WELL DEPTH (eoapieted) Oate sealed <br /> E k y of y <br /> CA -'i " `� � Sr ] � 1�' � ) �j� � ft. � ..-� G � <br /> �" (�N / 0 <br /> Numerical Street Address and C1ty of Mell Location or Oistance from Road 5. DRILLIN6 METHOD (if known] <br /> Intersection �'Cable tooi 4�Reverse 7[]Driven 30[]Oug <br /> � /��/� ��� 2[J Hollow Rod 50 Air �]Bored 11[] <br /> r t�/ `�f.�� Vl� <br /> Show exact location oi v�il � <br /> 3�Rotary 6(]Jetted 9(]Power Auger <br /> (in settion grtd rith •X') �( �Wcetch ma of weil location <br /> �/1. 6. OBSTRUCTIONS <br /> l /l� /�I / Yell obstrueted Yes � No <br /> ` Q <br /> V v v Obstructions ��Yes �No If obstruetions eannot be <br /> - � - - - •- -� ti_ <br /> � � . � ' '�} '/� re�ored. contact l�FI <br /> M - : -: -: -I- � - �,,�,V � betoro sealing. <br /> . ' - ' •- -' j � �. use <br /> ' � y.;, �Domesilc �Mbnitoring �Heat Loop <br /> __� ._� _ � . ' I � 20 Irrigation 50 Publie 9� Industry <br /> ' S ' 1 � j C�Y ---�' --- — / .ij,J Test Meli 6[J Munictpal 1Cl]Coonerclal <br /> .7 <br /> �—1 .it.---+ 7[]Air Condittoning il[] <br /> 2. PROPERTY OUNER'S NAME ress f different than 8. CAStNG(5) � <br /> praperty address indTcated above 1�.Black 4�,7hreaded 7[] <br /> �i��4Jr�- 20 Galv. 5[�Nflded <br /> 30 Plaztic fi0 SUtnless Steet � <br /> HARDNESS OF a /f�ft. <br /> 3. FpRNATION lOG COLOR FORM0.TION FROI4 TO ��^• to <br /> If not known, indicate formation log from new welt or nearby well. 1n, to ft. <br /> 9. SCREEN <br /> �5creened well froa���, co J>irc. <br /> �^- (I' known) <br /> ��0 �Open Hole froo�ft, to_ ft. <br /> 10. S7ATIC MATER LEYEL <br /> _�!� tt,(�baiow �]above <br /> land surfaee Date Measured �' "rl <br /> 11. WELlHEAO COMPlETION <br /> �Pitless AAapt�r �Pound Buried <br /> ' 2[]8asement offset � <br /> 3�Nell Pit ' <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINC�S PERFORATED, E7C. <br /> 12. GROU7ING INFORM0.TION <br /> _ 1�,[leat Ceaient �BentaMte � <br /> Grout material �f��J�to� ft, cu. yds <br /> 1J. NEAREST SOURCES OF CON7AMINATION <br /> • � teet �_dlroetion �1type <br /> Mell disinfetted before sealingt�Yes <br /> 14. PUMP �Removed �Not Present <br /> Type: 1[�SuMnersible 30 1.5. Turbine �Reciprocating <br /> y�Jet 4�CentMfugal 6� <br /> 15. EXISTING WELLS (Please sketch loe�ttons of abandoned and <br /> acLive wells tn remarks section or on back.) <br /> Other unused w�11(s) on propartyT �Yes �No <br /> Abandoned: [�Peneanent �Temporary []Not sealed <br /> 17. MATER MELL CONTRACTORS CERTIFICATION <br /> This �+ell was sealed under my �urisdlction and this report <br /> is true to the best of my knowledge and belTef. <br /> Lice e us�s� L1�se No. � <br /> . <br /> Address L ,,,� /r�( <br /> STgned Date <•9 <br /> ` Dat� -�S <br /> FFICIAL ABANppItED YELI RECORD (May b� used for Property Transfer) Nawe of Dril r <br /> It��'Asi': llLd lTSTB DSSD <br />