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