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� . STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
.1. LOCATION OF MELL MINNESOTA UNIQUE WELL N0.
(leave blank 1f not known)
County Nam� /�
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Tornship Naer Township b�L Range Number Sectton No. Fraction 4. MELL OEPTH (completed) Date sealed
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� 1 Sr CG5 7 �'/11��1 �' / ft. r d- 3 �
Numerical Street Address and C1ty of ell lotatlon or Dtstantt from Road 5. DRILLING METH00 (1f known)
Intersectton 1[]Cable tool CQ Reverse 7[J Dr1v�n 1(�]Du9
� � � 2�Hollow Rod 50 A1r �Bored 11(]
SAow exact location ot well
30 Rotary 6�Jetted 90 Parre�Auger
(tn section grid rtth 'X') SketCh nap of well locatlon 6. OBSTRUCTlONS
N wetl oestructea Q res f�no
_ ► _ _ _ ._ Obstructlons reanred Q Yes �No If obstructlons cannot be
� � � � remored, tontu t MDH
W _ . -• - � -I_ � - E before sealing.
. .
: ; ` T �. �SE
' y„�, �Domestic �Monitoring �Heat Loop
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2[�Irrlgatlon 5�Pub11e 9� Industry
-'- • -'- -
---- S . .iL �a:: �e�i oV ltunictpa7 1cL Commercl�l
�--�—1 .iL--+ 7[]Mr Conditioning 11[]
2. PROPERTY OWNER'S NANE FIa111ng Address if dtfferent tAan 8. CASING(5)
����` ` property address tndicated above • jL7}�Black IQ Thnaded 7[]
� 2fl Galr. 50 M�ldtd
3j]Plastle 6(]SUtnless Steel
NARDNESS OF � tn, to ` _ft.
3. FORMATION �OG COLOR FORWITION FROM TO
If not known, indiute formatlon log fros new well or nesrby well. tn, to ft.
9. SLREEN
❑Screened w�l l tro�_ft. to_ ft.
(I! knorn)
�Open Hol• fro�_ft. to_ ft.
10. STATI� M4ILR LEYEL
�s ft.�below �abor� / Q .
� land surfac� Oat� Meesured ` [
11. WELLNEAD COMPLETION
�Pitless Adapter �Found Buried
20 BasemenL offset �Q
30 Nell P1t
16. REMARKS, EIEVATION, SOURLE Of DATA - CASIN6S REMOYED, CASINGS PERFORATED, ETC.
' 12. GROUTING INFORMATION
1�]Neat Cement 2�Bentontte �
Grout materlal�P��from��to�ft. cu, yds
� — --- -- —�
13. NEAR�F,$7 SOURCES ��f CONTAMINATION
� feet J dlrectton ,.l1 D�.t�1 ��rpe
• Well dlsinfected befon sea11ng7 []Yes
14. PUMP �]Removed �Hot present
Type: 1[I Submersible �L.S. Turbine 5�Rectprocating
2�Jet �Centrlfugal 6�
15. EXISTING WELIS (Pleas� sketch locattans of abandoned and
� 1 active wells 1n rcmarks sectton or on back,)
,� Other unused i+ell(s) on propertyT �Yes �'tlo
Abandoned: �Permanent �Temporary �Not sealed
17. WATER WEII COIITRACTORS CERTIFICATION
This wetl was sealed under my Jurlsdlctton and this report
is tru to the be of my knowledge and belief.
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��1 f�\� `� �t i���;� .�... Gr/ �1..lL�
Llcensee Business Ilame License No.
Address � �s`�z�v� �
51 /� te .L
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9FfICIAI ABANOONED YELL QECORD (May be used for Vroperty Transfer) Name of Dr111�r
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