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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> I. LOCATIDN OF WELL MINNESOTA UNIQUE WELL N0. <br /> (leave blank tf not known) <br /> Coun,y Name ���� �� <br /> 'ownship 17ame Township umber Range Number Sectien No. Fraction 4. WELL �EP7N {completed) Date sealed <br /> Q E ; ; of , <br /> L�fl"`.� l �, s� r3.� a� � �� C ft. 3 _ 1 .�` // I <br /> 4umerical Street Address and Ci[y of Well Location or Distance from Road 5. DRILIING METHOD (if known) I <br /> fntersection 10 Cable tool 4[�Reverse 70�riven 10�]Dug <br /> � �+ . r <br /> � j y 1"� `/���, f1�„[ 2fli Hoilow Rad 50 Atr 8[�Bored 110 <br /> � L U �-(,y-..--�� ��I ���v'-�...- t� <br /> I 3� Rotary 60 Jetted 90 Power Auger <br /> ' S�cw ezact location �r well <br /> I (in section grid with "X") Sketth map of well lotation `� � 6. OBSiRUCTIONS <br /> !� <br /> � ��,� � Well obstructed Q Yes � No <br /> _ � _ _ _ ,_ _. � Obstructions removed� es �No If obstructions cannot be <br /> ' ' i removed, contact MDH <br /> ' ' I_ � before sealing. <br /> W _ . _ _ . _ . � _ E � <br /> i , , , T 7. USE <br /> - - - • '- -` � 1�Domestic 4[]Monitoring 80 Heat Loop <br /> i y ni. <br /> � ; _ ; ; I 2[� Irrigation 50 Public 90 Industry <br /> j 3�Test Well 6�Municipal lC�_]Commer�ial <br /> � 1 SL— 7�]Air Candittoning 11[] <br /> 2. PR�PERTY OWNER'S NAME Mailing Address if different than 8. CASING(5) <br /> ' property address indicated above 1[]Black 4�Threaded 7(] <br /> 2�Galv. 5�Welded I <br /> � 30 Plastic 6[]Stainless Steel <br /> HARDNESS OF <br /> 3. FORMATION LOG COLOR FORMATION FROM TO � in, to�ft, <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> 9. SCREEN <br /> �Screened well from�t. to � ft. <br /> � (If knawn) <br /> �Open Hole from_ft. tc _ ft. I <br /> i <br /> i 10. STATIC WATER LEVEL <br /> � �G ft. �below []above � <br /> land surface Date Measured - / <br /> 11. WELLHEAD COMP�ETION <br /> 10 Pitless Adapter 40 found Buried <br /> i <br /> 7�] Basement offset '[] <br /> 30 Well Pit <br /> 16. REhIAP.KS, ELEVATION, SOURLE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> 1�Neat Cement 21]Bentonite � <br /> I Grout material L from�to�)ft, cu. yds <br /> I <br /> i — — <br /> i i <br /> I 13. NEAREST SOURCES OF CON7AMINATION <br /> I ZC.� feet _�_ direction�� type <br /> INell disinfected before sealing? �Yes <br /> I � O <br /> I �{ 14. PUMP �Removed � Not Present <br /> I �/�O� Type: 1[� Submersible 30 L.S. Turbine �Reciorocating <br /> � 0 /��C„✓ 2(j Jet 40 Centriiugal 60 <br /> ✓\/ <br /> A 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> �nC�y active wells in remarks section or on back.) <br /> 2� �"� Other unused well(s) on property? �Yes � No i <br /> P��] Abandoned: [] Permanent ,Q Temporary �Not sealed I <br /> s� <br /> 17. WATER WELL CONTRACTORS CERTIFILATION <br /> �, ' This well was sealed under my jurisdiction and this report <br /> is true to the best of my �cnowledge ana belief. <br /> r2 � _G� ,r��� a � �7 � <br /> _�Licen�ee Business Na.e. Ltcense Na. <br /> C J-.�c, _�•�--: .0 <br /> -� <br /> Address <br /> Signed /� �� Date ��� � <br /> Date -�.�- Q <br /> FFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of 11 e <br /> ZXPQRTANT: PZLB WITH DESD <br />