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ABANDONED HELL RECORD
1. LOCATION Of TELL MINNESOTA UNIQUE WELL N0.
(tea" blank if not known)
Canty N'me Hennepin
Township Rem Township Number Relive Number I Section No. Fractionof y a. WELL DEPTN (completed) Date sealed
N
Orono 11811 i 23W Wr 33 SW sillS11 168 1t. 06/17/91
Numerical Street Address and City of Rall Location or Distance from Read S. DRILLING METHOD (if known)
lateroactlon 10 Cable tool 4[3 averse 713 Driven 1013 Dug
3140 Watertown Road Orono 20 Mallow Rod E]Air 113 Rend 1113
Show exact location of wall 313 notary 613 jetted 113 Power Auger
(in section grid with •X•) Sketch map Of well location
6. OBSTRUCTIONS
We11 obstructed 13 yes ® Me
If obstructions cannot be
-; Obstructions removed p yes 0 Ne
i removed. contact NDN
M - -•- •�- - E before.1a1109.
• 7. USE
T
- •- y,�. 129 Domestic C1 Monitoring 43 Neat Lamp
x4 - _ go Irrigation '.13 Public 90 Industry L
30 Test No" 10 memitipal uO Commerciai
70 Air Conditioning 130
2. PROPERTT OWNER's NAME ailing Address if different than G. CASING(S)
property address indicated oho" 10 Black 4M Threaded 713
20 Cygnet Place 2C7 aim• IO Welded
Harold Panuska Long Lake, I.V 55356 30 Plastic 40 Stainless steel
HARDNESS OF 4 in, to 1t.
3. FOWTION LOG COLOR FORMATION FROM TO
if net bow, indicate formation leg from new well or nearby well. in. to ft.
9. SCREEN
®Screened vat from_ft. to_ft.
(it Rnown)
0 Open mole from_ft. to_ ft.
10. STATIC WTEN LEM
86 jt.®below 13 above
lead value a0617te measured / /91
11. WELLNEAD COMPLETION
10 Pitless Adapter 40 Found Buried
213 Basement Offset 'n
313 Weil Pit
16. M ARKS. ELEVATION. SOMNICE OF DATA - CASINGS ROWED. CASINGS IERfOIIAM. ETC.
House has been sold. 12. OWING INFORMATION
1®eat Comsat 213 aatomite 313
Grout material 13 bags from 0 168.t. ea. yds:54
13. NEAREST SOURCES OF CONTANINATION
feet direction type
Well disinfected before smaling7 13 Yes
14. PUMP ®Removed 13 at Present
Type: Ila Submersible 313 L.S. Turbine go Reciprocating
20 jet 40 Centrifugal 10
1S. EXISTING KLLS (Please sketch locations of abandoned and
active wells to remarks faction or em back.)
Other unused welI(a) on property? 0 us 0 No
Abandoned: 13 Permanent 0 Temporary 0 But mled
17. PATER WELL CONTRACTORS CERTIFICATION
This wall was sealed under my Jurisdiction and this report
is true to the best of my knowledge ad belief.
oma 271
94
622"I riWa"ass � West "can" a.
Address L4agle P I-V .55359
stgaed pat,
06/18/91
Tan Stevens Data 06
DFFICM ANNNINED WELL RECON (Ney be used for.Property Transfer) Name of Driller
LR>PNImrs ISLE Mss!I7RlD