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ABANDONED WELL RECORD
1. LOCATION OF �ELL MINNESOTA UNIQUE WELL N0.
Coun[y Name (leave blank if not known) H 8 1 2 1 1
Henne in
Tovns�ip Hame To�nsnip NumOer Range NumDer Section No. Fraction 4. MELL DEPTH (completed) D�te sealed
N E k y of y
Orono 117N s� 23W w� 20 SE SW NW 113 "' 2/5/93 i
Numerital Street AdOress and Lity of 41e11 locatian or Dlstance from Road 5. ORILLING METHOU (1f known) I
Incersectian 1�Cable tool 4�Reverse 7[]Oriven 1�Dug I
2745 Ethel Avenue Orono, MN 55391 z�Ho„o„ Rod SpA,r �gartd ��p �
Shor exact locatlon of well
3�Rotary 60 Jetted �Powr Auger
(in sec[ion grid rith "X") Sketcn map of welt locatfan
M 6. OBSTRUCT(OMS
, Helt obstructed Q Yes � No
- � - - - -- -� - Obstructtons reiwved�Tes �No If obstructtons cannot Ce
_ f
i
renoved, contact MOH
11 - -X - • - . -I- . - E before saling.
. : : : � T �. �sE
y.(. 1�]Domesttc q�Mpnitoring �Heat Loop I
,;. _;, _ ; _'._ I 2j] Irrigatton �PuDitt � Industry I
I
1 30 Test Well 60 MuniNp�l 1��oa�e��i�� i
'-'--1 SL 1�Mr Canditionfny 110
2. P R O P E R T Y O W N E R'S N A M E M a i l tnq A d dress 1 f d ifferent than 8. CASING(5)
property address indlcated above 10 Black 40 Threaded ](]
Ben Jensen �w�� �w��a�d I
30 Ptasttc 60 Statnless Ste�l I
HARDNESS OF 2
3. FOfUlATION lOG COLOR FONMATION FROM TO �^• �� «•
If not known, indicate formatton log frou new well or nearoy well. 1n, to ft.
9. SLREEN
�Screened w�ll frw_ ft. W ft.
- (If known)
�Open Hol� fro�_ ft. to_ ft.
10. STATIC44�TER LEVEL
ft. [1l]belor �aDove
l�nd zurface Oate lkasured 2/5/9 3
11. 4ELLHEAD COlIPlETION
1� Pltless Adapter �Faund Buried
2[� Basement offsat � i
30 Well Pit �
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVEO, CASINGS PERFORATED, ETC. j
12. GROUTfNG INFOti1MTI0N i
1�Neat Cenent 2[]Bentonit� � �
House has been sold. �r��� �__�1�, 2� b�y� �ro. � �olZ?�L. ��. yaS•�g
— �
13. NEAREST SOURCES OF CONTAMIM1lTI0M
_ feet direction �YD�
Hell dlsinfect�d 6efon salingt � Yes
14. PUMP �Reroved �Not Dresent
TyDe: 1[1 Subarslbl� ��,5. TurOine �Reciprocating
2�Jet �Centrifugal fi0
15. EXISTING WELLS (Pl�as� sk�tcA locatlons of abandoned �nd
activf `+ells fn rt�arks sectlon or on back.)
Ot�er unuzed wll(s) on prop�rtyt �Yes �No
Abandoned: C1 Persa�ent �Te�porary �Not sealed
17. WATER 4ElL CONTRACTORS CERTIFIGTION --~
This well w�s sealed under my ,jurizdiction and this report
is true to the best af my knorledge and 6elief,
Stevens Well Drilling Co. 27194
Llcensq�„gy�f�pqW N�ee2 W. Ltcense No.
bc�+u i�i 1
Addrtsi Ma 1 e P1 ' MN 55359
Stgned �� Date 2/8/9 3
Tom Stevens u,t. 2/8/9
FFiCIAI ABANpOMEO YELL QECORD (May bt us�d for Proptrty Transfer) Naw of Dr111�r
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