HomeMy WebLinkAbout1990-02-22 Abandon Well RecordSTATE OF MINNESOTA DEPARTMENT Of HEALTH
ABANDONED WELL RECORD
LOCATION OF su
County Now 1Jyt/3�! ,.Nti
TewsMp NM Towson Number Range Num0ar Section No. Fwtloa a.
E k k of ii
Numerical Street Address and City of Well Location or Distance from Roof
Intersoctlon/��
Show nct 1Katlea of well
(L sactton pfd with '1a) Sketch map of well location
1f
®m®w
ME
MEIN
V—tatV
?. ►rAptm oma*s NAPE mmiting Address If different than
property address lndfcated, ove r�
NAADNtSS Of
S. FOWTION LOG COLOR FOWTtON rRON TO
If Mt kssawa. Indicate formation leg free new well or nearby well.
. SOURCE OF DATA . CASINGS KMDYEO. CASINGS ►ERFORATED.
MINNESOTA UNIQUE YETI NO.
(leave blank If net knew)
e soled
l G� ft. l C
S. ORILLIhJ MET1100 (if know)
1® Cable tool 40 Reverso 70 DrIvM 100 oug
20 No11ow Rod SQ Air I10larod 110
30 Rotary 40 Jetted C huger Auger
S. OGSTNKTIONS —
Wa11 obstrwctNle Too ❑ me
ONtruttiems removed WToo ❑ No If oMtrwttIWS cannot be
renv". contact Mel
bf ,re sealing.
7. USE
1M Domestfc
�-�i
Q NMItoring 40 Most LO"
20 Irrigation
![3 ►ub71c 10 lo"Stry
30 Test Wall
10 APICIpel ICC Camw cIaI
70Air Cenditloning IIC
G. r.ASING(S)
IM $lack
4M ThrMded 70
70 Gaiv.
SQ Molded
30 Plastic
do Stalmless SWi
Viy
In. to r J`_ft.
In. to ft.
9. SCREEN .�' _
[] Screened welt from � ft, to%f ft.
(I! knows)
❑ Open Net• from _ ft. to _ ft.
10. STATIC R LEVEL
0 ft. 0 below ❑ above
lend swrfaco Date Measured
11. WLLIMEA0 CO1PLiTION
113 Htlese AQata► C found Gwried
70 Easameet offset 10
313 well Pic
10 Neat Caamet 10 wotdMte 30
Grout material fmo; I`tk." !. cu. yds
11. NEAREST SOURCES Of CONTAMINATION
feat_ direction Lelci,type
Wall disinfected before sealing? ® Two
14. NW 0 Raved ❑ Not Present
Type: 10 Submersible 0❑ L.S. Turbine 10 Reclpoeatimg
20 Jet Q camtrifwtat Q
1S. EXISTING YELLS (►lgse Sketch tecatieno of aMmMded and
active will in re"s section or on back.)
Other unufad MIX($) On property,❑Tel Ile
AbandoRed: ❑ ►ermsneat ❑ Tamorary ❑ Not sw*o
17. WATER WILL CONTRACTORS CERTIFICA'IOII Y
This wall was sealed uoar my Jurisdiction ant w1v report
�. true to the be t of my knowlad9a and wi let
C% �
licanf WfiMil Nano L1tfaM N0.
Address
Sfgned l f/<... T' ate
Date .) 7
OFICIAL AGFNNINED WELL RECORD (Way to used for Property Trinafar) N.ma q1 Ors War
11111PeONIlAffs FZLE IR21 OQD I _