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Home My WebLink AboutWell info STATE OF MINNESOTA DEPART'P4ENT OF HEALTH . ' ABANDONED �HELL RECORD 1. LOtATION OF VELL MINNESOTA UNIQUE WELL N0. County Nama ' (lenve blank if not knorn) Tornshlp Nama Townsht umbp� Range Numbe� SeeLion No. Fractlon 4. WELL DEPTH (eompletedj Date aealed � � 7 '� a� � lo k�� 6 d ,t. lo ��. �, � Numarical Street Addrflas and Ctty of Well Loeation or Diatance from Road 5. ORILLING NETHOG (iP knoxn) Inte�seetton • 1�Cabie tool 4�Reverse 7(]DMren 10[]Dug I�I � O � � 2�Hollow Rod 5[]At� B[�Bored 110 i Sh w exaet loeation of we11 3�Rotary 60 Jetted 9�Pawe�Auger � (in settlon 9rid with •X'� Stetch map of we11 loeattan � N 6. OBSTRUCTIONS Yell obsLrvcted�1'ea � No - � - - = • - �-•-� ObsLruetions �eawved 0 Yes [�No If obstructlons cannot be ' � � � � remored contact MOH x _ _ ' � -'_ '+ _I'a _ E Defore sealing. . , � ; T �. use � � ,- '•; • ;- -� 4�:. 1�Doaiesiie 4�MoMtoring 8[a Heet Laop ,,,. , .:,,_,�,,..: _ I 2L][rMgation 5�pubt ic 9�Indust�y � � S � 1 30 Test Yell 6�Runlelpal 1CQ Commerctal ' 1��----+ 7V Air Condittoning 1][] 2. PR ERTY OIINER': NAME Nailing Address 1f different than , 8, CASIHG(5) �� property address lndicated above �1aek 4�Threaded 1� t zQ c�t�. sp u.�aea 3=]Plastit 617 SWlnleas Steel • HARONE55 OF ' 3. FORHATION LOG COLOB FORMATION FROM TO ��^• to�ft. If not known. indltate farmatton loq from new we11 0�nearby rall. 1n, to fC. - 9. SCREEN ' . �Streened we11 }rom_ft. to__ft. (If known) ❑Opan Hole ' from_�fL. to�_ ft. 10. STATIC y�ATER LEVEL , �� tt.�baiow �above . iend aurta�a Date Neesurad � 11. WELIHEAD COMPlETION 10 Pltiesa Adapter �Found Buried �BasemenL offset '� 3Q Yell P/t 16. REMARKS, ELEYATIOM, SOURCE OF �ATA - CASINGS REMOVED, CASINGS PERFORATEO. ETC. � . 12. G UTING INFOW4ATION 1,(�Neat Cement 2�Bentonita � � Grout mata�lal C'O.YL�e�.�from o ft. cu. Yds , 13. NEAREST SOURCES OF GONTAMINATIOM , _ ieet ��rectian LYPe Mell dlslnfeeted before sealingT�']Yes , II 14. PUMP �Removed �NoL Present I ' , Type: 1Q Submerstble 30 L,S. Turbtne �Retiprocating � , �Jet a0 Centrifugai 6� • ; � �� _ 15. EXISTING NELIS (Please aketch laeattons oP abandoned and I '� active welis tn remarks saction o� on Daek.)� � �' Othe�unvaed wall(s) on prope�tyT �Yes �No ' ' I sy ,�� G,' a;� � Abandoned: C1 Permanent �Temporary []Not seeled ' . � z,, +-� U 17. HA7ER MEIL CONTRACTORS CERTIFICATTON This well was sealed de�my�urlsdietlon and this report 1s true the Dest my knoNledge a e f. t 1MA�' 4 �992 �✓' l� .� ltcensee uslness Name Ltcense No. . Addresa ' Stgn� - Date � Date � FFICIAI.ABAIVppNED YELL P.ECOItO (May be used for Proparty Transfer) Name of Dri a� V ZXPC�TANTi PZLB WZTlf DBSD ;.,`c^�i - . � ��,d''.�P.-�� .,. ...,,. ..,� .._ . ,. . _ . ` - ' , .... ,. , ,,, . - . . , 'i;,�,t',:d'�"