HomeMy WebLinkAboutwell info — �.,�—
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED IiELL RECORD
1. LOCATiON OF YEII MINNESOTA UNIQUE WELL N0. HH1�99
Count Name (�eave blank 1f not knorn)
Y Henne in
Tow�ship M�ne Townzhtp NumDer Range Number Section No. Fraction 4. HELL DEPTH (co�pleted) Date sealed
n E k �, of y
or �� ft.
0 s � 115 10/9/92
,
umertcal Street Address and C1ty af Well loca[ion or Distance from Road 5. DRILLING METH00 (1f known) I
Intersection 1�Cable tool 4�Reverst 7(]Orlven !�Oug �
2470 Dunwood Avenue Orono �"°„°" Rod �a,� �a°��a ��O �
Show exact locatlan of well 3❑Rotary 60,letted 9[]Power Auger
(in zectlon grid r1tA "X•) Sk�tch map of wll locatton
N 6. OBSTRUCTIONS
x � Hell oEstructed Q Y�s 9(��-+ No
- � - ,- •- -` Obstructtons reaqved�7es []No If oEstructlons cannot Ce
i
M _ : _ _ ; � , - reaoved, cont�ct MOH
, . -�- ' E before se�ling.
- _ ; ; . : T �. �sE
- ' y�. 1�Domesttc 40 Monitoring �Heat loop
.�_ _,. _ ' , I 2[] Irrigatton 5�Publtc S� Inaustry i
1
� 3[]Test Well 6�Municlp�l 1C(]Caaerct�l �
% 1 ..iL )[]Mr Condltioning I1(] I
2. PROPERTY OWNER'S NAME Na111ng Address tf dlfferent th�n 8. CASING(S)
property addrezs lndtcated above 1[�Black �Thrt�ded 7(� i
2470 Dunwoody Avenue 2Q Galv. 5[]Yelded
Loren Ri chards Wayzata, MN 55392 3p v,.:t,� ep s�.,��e5, Steel �
HARONESS OF I
3. FOW�ATION I.OG COLOR FORMATION FROM TO 4 �O' L0 ft• I
If not known, indit�[e formatton log fron new well or nearby well. ��. Lo f� �
9. SCREEN
�Stre�ned w�ll fro�_ ft. to _ (t, I
(if known)
�Op�n Hol� (rp� ft. to ft.
10. STAT[C YATER LEYEL
Ei5 rt. �ator p,00�e
land surfaca O�te Measured lO f 9 f q7
�
11. WELLHEAD COMPLETION
10 Pltless Adapter �Found Buried �
2�] Basement offset � i
3[]Mell Pit '
16. REMARKS, ELEVA7ION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
12. GROUTiN6 lNFORMIITION �
1�Neat Cement 2[]Bentonit� � �
HOUS2 hdS been S0�C� Grout atertal q h�_tro��toj„�jtt. cu. yas
I ' -- — —
13. NEAREST SOURCES OF CONTAMINATION
_ fett direciton LYD�
Mell dlsinf�ct�d befor� se�ling7 � Yez
14. DUMP �Reooved �Not Pr�sent I
TYpr. 1[I Sub�rstbl� �LS. Turbina �Reciprocating I
2[]J�t �Centrifugal 50 I
15. EXISTIN6 YELIS (►l�as� sk�tcA locatlons of abandoned and
�ct1v� w�lls tn raarks s�ctlan or on back,)
Othar unus�d wll(s) on prop�rtyt �Yes �t10
, ACandoned: [�Pernanent �Teaporary �Not seeled
U. 4ATER MELL CONTRACTORS CERi1FICATION
This well wai sealed under my j�risdiction and this report
is true to the Dest of my knowledge and belte(.
t 194
Llcens�� Buslness N�ee Lfcense No.
Addreis 5 g
Sfyned C �ti1-.� Oate ��
R�nri�/ �lnhntnn n,c. 10/12 g2
FFiCIAI ABANppNED 4ELL RECURO (May b� used for Grop�rty Transfer} NaM of Or111�r
L�CRTA/7't lZLB MZTS DdBD