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