HomeMy WebLinkAbout1989-11-09 Abandoned Well RecordME
STATE OF M [ iN ESOTA DEPARTMENT OF HEALTH
ABAND011W..D WELL REC'ORD
1. LOCA11411 OF WILL
County Nate % �
Townswip Noxi Township NiAer Range Nufter I Section No.1 Fraction
C7_l E t s of t
C��t,•U�-,� / ! ) Sr j 3 �
/ v c�
Numerical Street Address and City i f yp'i Location or Distance from Road
M
Show watt location of weii
(in sectION grid with 'Y')
N
MINNESOTA UNIQUE WELL NO.
(leave blank if not known) f I
a. WILL DEPTH (completed)
,-)6)ft.
Dau staled
S. OR I L L I N6 MIE T1t00 (ft a nape )
a Cable tool 40 Ne.ent 70 Driven IC0 Dug
20 10011 ow Rod SD Air 10 isred 110 _
10 Rotary 60 Jetted ill'] Fewer Auger
Sketch mep of wall location 6. ORSYINKTIO"
Well obstructedi2Yes ❑ Ne
Obstruct ons reme"d (eYes ONO If obstructions cannot be
relieved. contact ON
before waling.
5
►-�-� 1 w
2. PROPERTY OMA'S NA1E Mailing Address if different than
_ * _ _O property address indicated above
"Afl S OF
1. FORINT 1011 L06 COLOR FORINT ION FROM
If not known. Indicate fdrfation tog freM new well or nearby well.
7. USE - --
1m Omstic 40Menitorl" loneat Loop
20 irrigation 10 ►Witt go Indwstry
U Test W11 1 i0 AM i i i pe l MOL] Coa>arerc 4 0 1
70 Air Conditioning 110
a. CASIN6(S)
10 Black 40 Tkmdid Cl
20 6a 1 v . 10 lie 1 ded
30 Plastic 40 Seamless SU.1
TO 10. to i ft.
in. to ft.
I. SCREEN
❑ scroomed well frees 1-1�7-f t. to -i:kLlft.
(!f thorn)
❑ Open Mole from ft. to ft.
10. STATIC TER LML
ft. ® below ❑ move
load svrfoce Rett Measured
11. WELLHEAD COMPM101
1❑ Pitless Adopter V ►own! Buried
28 114"ment offset
10 will Pit
16. RFOARKS, ELEVATION. SOURCE OF DATA • CASINGS REMOVED. CASiOGS PERFORATED. ETC.
12. GR% flN6 INFORWTION
1n Nest Cewent 20 News Ito 10
Grout material '! from 4�-to--e ft. cu. yes
13. NEAREST SOURCES OF CONTAMINATION
feet j tf-` direction --A-. type
If Wall disinfected before sealing? ® Yes
i 14. PUMP ® Romm"m ❑ Not Present
Type: 1(_i Submrsible 10 L.S. Turbine !0 Reciprocatinq j
41 Jet 40 Centrifugal 110
i
OFFICIAL AL%Ntx`.NEO WELL RECORD (Limy be used for Pr-iperty Transfer)
1!4M!Y! t FUN RR 17 DINVO
1S. EaiSTIN6 WILLS (Please sketch leutiows of soaneenod and
active wells in remorks section or ,n batt.
Other unused wei l (s) on property? (3 Yes jo No
Abandonea: ❑ Peri mmt ❑ Temporary ❑ Not sealed
17. WATER WV L CONTRACTORS CERTiFiCATiON
This well was sed led under my jurisdiction and this report
Is trU* to the best of way knowledge and belief.
Address
■■N
MINNESOTA UNIQUE WELL NO.
(leave blank if not known) f I
a. WILL DEPTH (completed)
,-)6)ft.
Dau staled
S. OR I L L I N6 MIE T1t00 (ft a nape )
a Cable tool 40 Ne.ent 70 Driven IC0 Dug
20 10011 ow Rod SD Air 10 isred 110 _
10 Rotary 60 Jetted ill'] Fewer Auger
Sketch mep of wall location 6. ORSYINKTIO"
Well obstructedi2Yes ❑ Ne
Obstruct ons reme"d (eYes ONO If obstructions cannot be
relieved. contact ON
before waling.
5
►-�-� 1 w
2. PROPERTY OMA'S NA1E Mailing Address if different than
_ * _ _O property address indicated above
"Afl S OF
1. FORINT 1011 L06 COLOR FORINT ION FROM
If not known. Indicate fdrfation tog freM new well or nearby well.
7. USE - --
1m Omstic 40Menitorl" loneat Loop
20 irrigation 10 ►Witt go Indwstry
U Test W11 1 i0 AM i i i pe l MOL] Coa>arerc 4 0 1
70 Air Conditioning 110
a. CASIN6(S)
10 Black 40 Tkmdid Cl
20 6a 1 v . 10 lie 1 ded
30 Plastic 40 Seamless SU.1
TO 10. to i ft.
in. to ft.
I. SCREEN
❑ scroomed well frees 1-1�7-f t. to -i:kLlft.
(!f thorn)
❑ Open Mole from ft. to ft.
10. STATIC TER LML
ft. ® below ❑ move
load svrfoce Rett Measured
11. WELLHEAD COMPM101
1❑ Pitless Adopter V ►own! Buried
28 114"ment offset
10 will Pit
16. RFOARKS, ELEVATION. SOURCE OF DATA • CASINGS REMOVED. CASiOGS PERFORATED. ETC.
12. GR% flN6 INFORWTION
1n Nest Cewent 20 News Ito 10
Grout material '! from 4�-to--e ft. cu. yes
13. NEAREST SOURCES OF CONTAMINATION
feet j tf-` direction --A-. type
If Wall disinfected before sealing? ® Yes
i 14. PUMP ® Romm"m ❑ Not Present
Type: 1(_i Submrsible 10 L.S. Turbine !0 Reciprocatinq j
41 Jet 40 Centrifugal 110
i
OFFICIAL AL%Ntx`.NEO WELL RECORD (Limy be used for Pr-iperty Transfer)
1!4M!Y! t FUN RR 17 DINVO
1S. EaiSTIN6 WILLS (Please sketch leutiows of soaneenod and
active wells in remorks section or ,n batt.
Other unused wei l (s) on property? (3 Yes jo No
Abandonea: ❑ Peri mmt ❑ Temporary ❑ Not sealed
17. WATER WV L CONTRACTORS CERTiFiCATiON
This well was sed led under my jurisdiction and this report
Is trU* to the best of way knowledge and belief.
Address