HomeMy WebLinkAbout1991 - abandoned well record •
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION OF WELL- 1 MINNESOTA UNIQUE WELL NO.
County Name -/ •
(leave blank if not known)
J I�
Township Name Township Nu0Ser Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed
/� o/ •^/� E 4 la of is ) )
I(24-..-- ----
/1 ..-" am /C S r d .J �) )/ ./ -7 C) ft. /rJ - 1 rte-- 61/
Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known)
Intersection 1Cable tool 40 Reverse 70 Driven 100 Dug
6 O / LL. / 20 Hollow Rod 80 Air 40 Bored 110
30 Rotary 60 Jetted 90 Power Auger
Show exact location of well
(in section grid with "X") Sketch map of well location
N 6. OBSTRUCTIONS
Well obstructed Ries 0 No
;IC- - - - - - -- • Obstructions removedla Yes 0 No If obstructions cannot be
(,L,,,,G'L' removed, contact MOM
W - - - - • - - . -I- - E —A before sealing.
- T 7. USE
, 4.C. I�Domes'tic 40 Monitoring 80 Heat Loop
20 Irrigation 50 Public 90 Industry
I
, 1 � 3[j Test Well tU Municipal 1C0 Commercial
t------1 SU--+ 70 Air Conditioning 110
2. PROPERTY OWNER'S NAMEE� Mailing Address if different than 8. CASING(S)
___c_./ ..-- property address indicated above 14Black 4pLThreaded 70
Cr 20Galy. 50 Welded
','.�- ` • 3L]Plastic 60 Stainless Steel •
HARDNESS OF ('
3. FORMATION LOG COLOR FORMATION FROM TO J Tn, to s ft.
If not known, indicate formation log from new well or nearby well. in. to ft.
9. SCREEN
{aScreened well from,7)y ft. to°-7 0 ft.
��11
(If known)
(9 J.?D 0 Open Hole from_ ft. to_ ft.
10. STATIC WATER LEVEL ,
0 ft. (_below 0 above
land surface Date Measured /...) -1.2- G 7e
11. WELLHEAD COMPLETION
10 Pitless Adapter 40 Found Buried
20,Basement offset 50
30 Well Pit
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC.
12. GROUTING INFORMATION
I1 Neat Cement 20 Bentonite 30
Grout material from_to ft. cu. yds
_ 1
- --� 13. NEAREST SOURCES OF CONTAMINATION
42 feet i:, - direction 6X•'Z--11t -, type
Well disinfected before sealing? 0 Yes
14. PUMP f'.al Removed 0 Not Present
Type: 10 Submersible 30 L.S. Turbine 1 Reciprocating
[� 3
laget 40 Centrifugal 60
Ea 3 1 1991 15. EXISTING WELLS (Please sketch locations of abandoned and
active wells in remarks section or on back.)
Other unused well(s) on property? 0 Yes ANo
Abandoned: 0 Permanent 0 Temporary 9 Not sealed
17. WATER WELL CONTRACTORS CERTIFICATION
This well was sealed under my jurisdiction and this report
is true to the best of my knowledge and belief.
/� 0 ?J 7 .6
1t t�^ �/�tl.� L��
Licensee Business Name yJ License No.
C7J- 3 o is(---i -e7��i
Address '?-L�-/w`- 4-e 4. /
Signed j�-f,.,.-,y -fi t�.Sf Date 1.2 .2.P 7/
k� � Date i -'' 9.'tName of Dr lie
FFICIAL ABANDONED WELL RECORD (May be used for Property Transfer)
I1�Cy2T.1NT: PILE WITH DEED