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