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Home My WebLink Aboutwell info �l '� STATE OF MINNESOT.4 DEPARTMENT OF HEALTH ABANDONED NELL RECORD 's 1. LOCATION OF MELI MINNESOTA UNIpUE WELL N0. County Name (ieave blank 1f not known) 1•`y' ,_� TownsM p Name Towns D NumD r Range Number Section No. Fraction 4. WELL DEPTH (completed) Oate sealed ' � E 4 M ot y ; Q(�, / ` Sr � �{ � �� ft. 7/�iJ. � % �yJ l � Numerical Street Addresi and C1ty af Wetl Locatton ar 0lstance from Road 5. DRIILING METHOD (1f known) Intersec N on 1�Cabte tool 4�Reverse 7[]Drlven 1�Oug ,i,': YD� 20 Hol law Rod 5[�A1r �]Bored 11[] Show exact toc�tion ot well 30 Rotary 6Q Jetted 90 Power Auger (in sectton grid rlih 'X') Sketcb map of well lotatton 6. OBSTRUCTIONS ' N , well ob:tructea p res�] no _ � _ ._ _. ODstructlons removed�Yes �No If obstruetions cannot be � � � naaved, contact MOH z W - _ -•- -I- E beforc sealtny. _ . . : : _ T • �. �sE " ' y R, • �Domestic 4�Monttortng �Neet loop �_ , ' F�'j irr;gatton a�7uoitc �Industry t • � '��J � 30 Test M�ll 6=]Muntclpal 1C0 Commercial r--1 SL 7[]Air Condltloning 11Q 2. P RTY OWNER'S NAME Ma111ng Address if different than 8. CASIN6(5) property address 1ndlcated above 1�Black 4�Threaded 7[] '� n C—_ 2[]Galv. 50 Welded / ��.� 30 Plastic �]Stainless Steel HARONESS OF '� 1n, to�ft. 3. FORMATION lOG COLOR FORlNTION fROM TO If not known, tndicate formatton log fron� new we11 or nearby well. 1n. to ft. 9. SLREEN �Screened well from_ft. to_ft. '' (I! known) -;�� Open Hol� fron_ ft. to_ ft. -Y 10. STATIf�UV(ATE�t IEVEL ti I U tt. Q below �abov� ,. l�nd surface Date Meesured_� �� 11. WELLHEAD COMPLETION �;� 1�Pitless Adapter �Found Burled +; � 2�Basement offset '� �� 30 Hell P1t � 16. REMARKS. ELEVATIOB. SOURLE OF OATA - CASIN6S REMOVED, CASiNGS PERFORATED, ETC. �,��. 12. GROUTING lNFOR141TION I�Neat Cement 2�Bmtanite � " Grout materlal �p�2r/_.�.�7`7rom�to�ft. cu, yds ;; ;.i — — —i 13. NEAREST SOURCES OF CONTAMINATION _ feet dtroction type ;� Hell dtsinfected Detorc sealingt �Yes � 14. PUMP �Removed �Not Present � � �� j j Typr. 1[1 Submersible � L.S. TurClne �Reclprocating .��'� �� ' 2�`Jet a0 Centrifugal 60 �, � � 15. EXISTING WELLS (Pleas� sketch louttons of abandoned'and ;� activ� we11s 1n remarks section or on back.) Other unused w�ll(s) on propertyT �^Yes � No � + ADandoned: �ermanent �Temporary �Not sealed �F R � � 1�.�1 v� 17. MATER WELL COBTRACTORS CERTIFICATION , This rrell was sealed under my �urisdlttion and th15 report Ts tru to the b t of my knowledge and beltef. ,`� z vl�� Licensee�Buslness t/ame Llcense No. ..� • � ' � ii Address � � - $igned ~ e l "� � Dat� :� OFFiCIAL ABANOONED MELL RECORO (May b� used far CroD�rty Transfer) Rame of Ortil�r ,.,i IXPLBtTANT z lZLS �rIT9 DBBD STATE OF MINNESOTA DEPARTMENT OF HEALTH ABANDONED NELL RECORD 1. LOCATfON OF MELI M(eaEe�tankNf�noE Wnown)NO. County Name Township Naaw Tornshtp umblr Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed Ly E 4 ti af 4 ^ D /7 5r �-3 � � — ;; / ! ft. �/ � v Numerical Street Address and Ctty of Well Location or Diztance from Road 5. DRILL G METHOD (1f known) _ Intersectton 1�Cabl� tool 4[J Reverse 7(]Drlven IQ]Dug 6 J J/ 2[]Hollow Rod 5[]A1r �]Bored 11[] C ;s� Show exact 1outlon of well 3�Rotary 6�Jetted 9�Power Auger � (tn sectton grtd rtth 'X') Sketch ayp of welt loutlon �' 6. OBSTRUCiIONS y� N Wel1 obstructed Q Tes ,(�r No ;� _ t _ _ _ ._ _. ODstructions removed 0 Yes �No If obstructlans eannot be � � � � ' reaaved, contact MDH � M - ' -• � -I- ` E before sealtnq. ,�, - -+ . : , � T � �. �sE ��. - - •-�'� y�,d. l�rn C�r.-•.,.,c .J P..�.�tortny �heat LooP •�c ! ' ' • ( 20 Irrlgallon 50 Publte 90 Industry !`�� ..�. . ._�.. _.,.. ._,. ' S ' 1 30 Test Well 60 Municlpal I[Q Comaeretal ►---1 .iL----� 7[]A1r CondTHoniny 11[] 'i" 2: PR RTY OWNER'S NAME Matltng Address if different than 8. CASIN6(S) �j� L�� Droperty address indtcated above 1�Black IQ Thre�ded 7C1 s;� ��.� zp c.i�. ,p w.ia.a ",;. � 3�Plastle 6�]Stainless Steel '� HARDNESS OF `< 3. FORMATION lOG COLOR FORMATION FROM TO ��^• to�tt. �; If not known, indicate formatlon log fron� new well or nearby wll, in. to ft. �t :'T 9. SCREEN �Scretned well fros_ ft. to_ft. (If known) �Open Nol� fron_ft. to_ ft. fp 10. STAT� MATER LEVEL !� _�� ft.Q below �abov� � , land surfac� Date Measured[{�/l�� ,. .'� I1. WELLHEAD COMP�ETIGN 10 Pltless Adapter �Found Buried ;�� 2�Basement offset '[} �«, 3�Hell Ptt 16. REMARKS, ELEYATIOM, SOURCE OF DAiA - CASINGS REHOVED, CASINGS PERFORATED, ETC. 12. GROUTING INFORM0.Ti0N I�Neat Cement 2[]Bentonite � � Grout material (��from�o_ ft. cu. yds _ _ � :;� 13. NEAREST SOURCES Of CON7AMiNA7I0N _ feet directton type � ' l D � , Hell dlsinfected beforc sealing? ,�Yes ; ��a`/ l=�- �Removed �Ylot Present � F 14. PUMP Type: 1[�Submersible �L.S. Turbine �Reclprocating 20 Jet a�Centrlfugal 60 '6^ � ��a� 15. EXISTING WELLS (Plessa sketch louttons of abandoned and ''" R Q� � � �J:i: active wells 1n remarks seeiion or on back,) "� Fi o Other unused w�l l(s) on property?„�'Yes � Bo c�`, Abandoned: �Permanent �Temporary �Not sealed "' :'� ;1- ll. MATER WELL CONTRACTORS CERTIFICATION �q This well was seeled under my ,�urisdictton and tMS reDort `� � is true the st of my knowled beltef. �-�a � ._ �j ' -- �� ,; ;.. L1cen �ys1n s �iF�K Llcense No. �r� C� �j -" 31 Address � � �:� r - Slgned � �� Date � � � �� 9 • � Oat� ! �' '� OFFICIAL ABANDONED VELL RECORD (May be used for ProDerty Transfer) � Name of Drtller ��"K� ZXPCgtTANT: 1�ZL8 IVITH DSBD STATE OF M[NNESOTA DEPARTMENT OF HEALTH 1 WATER WELL RECORD MlNNESOTA UN/QUE WELL NO. ��O� Coun[y Name �7 w ti Il c p 1 fl Minnewla Sfatrfes 156A.01.08 /�warp.somae Townahip Name� ownship Number Range Number Section No. Fraction 4.WELL DEP7'H lcompktedl Date o(Completion Or�r,o 117f3 ° 23 W w 7 SE ��SE ��NE�� i 8� r, i�.rR��: 27 , �991 Numerical Street Addiess and Ciry of Well Lcea[ion or Distance from Road Intersection. 5.DRILLING METHOD ,�,Q3•7 �a�•1� R��'., �Y•DI'�� MM ,.�]�36`� ❑CableTool OReverse ❑Driven ❑Dug ow exact location d well in sectbn grid with"X." Sketch map of well location. �HollowKod ❑Air ❑Bored ❑ N � � � i Addition Name ��.1 Rotary ❑Jetted ❑Power'Auger _� ~ _1 -1 6.DRILLING FLUID � � Biock Number g�.�Q 1 'C'` �`Li 1 Y' �"��'1 --�- - � w i �� - �- � . E 7. USE i _I_ _s_ _� __ ;�[}�Domestic ❑Monitoring ❑HeatPump � � f�mi. ��Number ❑Irngation O Public O Industry ' � � ❑Test Well C]Municipal ❑Canmerciai i � —r' j ❑Air Conditioning O I �m��—� B.CASING HOLE DIAM. 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ��B�a�k HEIGHT:�Iow -''�J Threaded �_„�,� indicated above. Surface tt. ❑Galv. ❑Welded Don ..S��c�, �� Drive Shce? Yes�No_ ❑Plastic ❑ t' 1 � � ?� } ��.�o �Q u. wc�gn� �' in�.ir�. ��. c4r.r„1�. 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to fL Weight IbsJft. �n. to�t. FORMATION in.[o (L Weight IbsJ(t. �n. to-It. ��.Gy Sc ::c".��.i �`•r�T.J�? :^i� � �FJ 9.SCI�EN Or�openhole ��G}1�'2SOF1 trom tt.to. ft. Make 7 y. �`Z^�� jrC3 vaf� C7� 1C�,'L� Type '�tt�1.�1.1��J' ..�.'aL:.�tyl Dlam. 41� `' f t . SIoVGauze a 1'�t Length � san� & clav ��r�wn ^oft 12� 1.`_.8 3 ft . �xtn�'�Ti"c�ii � Set between f[.and it. ]0.�"I�'�f WATER L c i a y � s a r.r� ��r��I :3 c�f t �,�',$ �� ft below O ahove Date Measured ��7 7 land surface ^� 11.PUM�ING LEVEL(below I d surface) �O £it�n'�i fJc l:1�i;� :�r a.y ¢?�.i r"�" ��6 � !�..'- .� (t.a([er � hrs.pumping g.p.m. ft.after hrs.pumping g.p.m. s�G1 1T'c�Z �=j I e�Y � rC� �L7-� ��`1 12.HEAD WELL COMPLETION t � L!�� `�Y tless adapter manufacturer �Q�1�0 r Model ��_-� iBasemen[otfset ❑At least 12"above ground Plastic casmg protec[ion _WELL GROUTED? ��'Yes ❑No ❑Neat Cement �Q Bentonite L7 ..— Grout material from to tt.cu.yds. �PR 2 2 19.., -- ]0.NEAREST SOURCES OF POSSIBLE CONTAMINATION '�� (eet S direction 1 SI�1'�E� ?i Z Li2!11;1 l"2C� �C� ;YPe Weli disintected upon completion? E'Yes ❑No 15. PUMP n Date installed `'/?7 ❑No[installed Manufacturer's name A2 rtna t o r Model number HP J��Vol[s L'�� Length ot drop pipe tt. Capacity 1� .g.p.m. s e�l Material of drop pipe _._ Type: C�6ubmersible ❑L.S.Turbine L]Reciprocating ❑Jet ❑Centrifugal L] l6. ABANDONED WELLS Unused well on property? -'t7 Yes ❑No Use o semnd sheef,if needed �� C��Permanent ❑ Temporary ❑ Not sealed 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. � 18.WATER WELL CONTRACTOR CERTIFICATION This well was drilled under my jurisdiction and this repor[is true to the bes[of my knowledge and belief. T,(?LUttiG"lE'r' W`l I ITt� , IL�i.!,�.� V i��5�"i'�5"°'��!n 5 5�8 6 License No. Address n �+ Signed Date �`1 �J C�:iZT!��ori2 Representa[lue �/� ��z Date Name of Drtfler LOCAL COPY " ' ' S��4� : '� �` ms� ': `� � �'_ `; ��'k HE-01205-03(Rev.9/88) 2iez�o�i�