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STATE OF MINNESOTA DEPARTMENT OF HEALTH � <br /> ABANDONED NELL RECORD <br /> 1. LOCATION OF MELL MINNESOTA UNIQUE WELL N0. <br /> County Name � _. (teave bTank 1f not knor+n) <br /> �T nship Name Townshi Mumb Range Number Sectton No. Fraction A. NELL �EPTH (compteted) Date sealed <br /> ` � E 4 4 of y � <br /> � s� �-3 U �� $!v` -� ��� ft. ��� �'J <br /> Numertcal Street Address and City of Mell Locatton or Distance from Road 5. DRILIING METHOU (tf known) <br /> Intersectton 1�Cable tool 4�Reverse 7[]Drlven la]Oug <br /> �� '7,J� ��..� �-'��, 2[�Hotlow Rod 50 A1r �]Bored 11(] <br /> Show exact locatton of we11" <br /> 30 Rotary 60 Jetted 90 Power Auger <br /> (in settton grld rith 'X') Sketth map of welt loutlon <br /> N 6. OBSTRUCTIONS <br /> , Mell obitructed�Te3 ,� No <br /> _ � _ _ _ ._ _. Obstructlons removed�Yes �Mo If obstructlons cannot be <br /> . � removed, contact MDH <br /> W _ ; _ _, _� _I_ � _ E before sealing. <br /> : : : : T � �. �sE <br /> " y.,�, 1�Domestic AQ Monitortng 80 Heat loop <br /> 1 . . , ( <br /> Z[]Irrlgation 50 Publtc 9� Industry <br /> .�- • -'- - <br /> .�• � a�. .. �1.•, q1 y,_.�. .i ..r�^ — <br /> S ' " '. .. _ �_ _,.v.._.__,.....,.. <br /> �----1 .(L—� 7[]M r Condlttoning 11[] <br /> 2. PROPERTY WNER'S NAME Na111ng Address if different than 8. CASING(S) <br /> property address tndicated above 1�Black 40 Threaded 7(] <br /> � " 2[�Galr. 5�Helded <br /> �� 30 Plasttc �]Stainless Stee1 <br /> HAkONESS Of � <br /> 3. FORMATION lOG COLOR FORMATION FROM TO tn, to �) ft. <br /> If not knawn, indicate farmation log fron� new well or nearby well, in, to ft. <br /> 9. SCREEN <br /> �Screened well from_ ft. to_ ft. <br /> (If knawn) ' <br /> �Open Nole from_ ft. to_ ft. �,fi <br /> 10. STATIC}iA�ER LEYEL <br /> �S �� ft. Q below �abave / <br /> land surface Dtte Measured-������. <br /> r'; <br /> 11. MELLHEAD COMPLETION <br /> 10 Pttless Adapter �Found Buried <br /> 7�Basement offset 50 :� <br /> 3�Well Pit <br /> 16. REMARKS, ELEVATIOII. SOURCE OF DATA - CASINGS REMOYED, CASINGS PERFORATED, ETL. <br /> 12. GROUTING INFORf4lTI0R <br /> I�Neat Cement 20 Bentonite � <br /> � <br /> ` Grout materlal r,Q�n,,�„�,+ from�to� ft, cu, yds <br /> 13. NEAREST SOURLES OF CONTAXIkATIOX <br /> _ feet dtroctton type �� <br /> Nell dlsinfected beforc sealing? �]Yez �' <br /> 14. PUMP ,�Removed �Not Present <br /> Type: 1[�Submerslble �L S. Turbine �Reciprocating ;y <br /> �" ' 2(�Jet 40 Centrlfugal 60 <br /> 1... <br /> �^'°� ,�t-' 15. EXISTING MELLS (Please sketch locattons of abandoned and <br /> � - active welis in rcmarks sectton or on back,) <br /> �� Other unused ++�11(s) on praperty7 (]Yes �Mo ��'j� <br /> Abandoned: []Permanent �Temparary []Not sealed <br /> ,i <br /> 17. WATER WELI LOt1TRACTORS CERTIFICATION ';� <br /> r �; � TM s well was seeled under my ,Jurisdiction and thi5 report y <br /> �1,1� x, I� is erue to the b st of my knowledge and belief. <br /> � 2�� o � <br /> licensee�Business Name Llcense No. <br /> Address -, � � <br /> r <br /> - $tgned Oat! � l <br /> � Oate � � <br /> OFFICIAL ABANOONEO WELI RECORO (May be used for Property Transfer) hame of Dr111er <br /> L�IPQRTANTr PZLS MITH DESD <br />