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ABANDONED WELL RECORD
1. �otaiIOn oF uEll MINNESOTA UNIQUE WELL N0.
County Name � ��eave blank 1f not known)
)r'L� ,iG.
Township Hame Townsh'- Numbe.r Range Number Section No. Fraction 4. NELI DEPTH (compteted) Date sealed
�1 , r_ / E k k of y
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` ^ � �'�l ��r !l'>�.9L- I .,� � � . � f t. � t/J `i )
,,���. �; s ��, .. w <-,�� �'��>��,,;�.. j����,��- �: ; ; —;/��.,
Numerital Street Addresz arid Lity of l�ell Location or Otstante from Road � 5. �RILL7NG METHO� (if known) �
Incersection /� 1�Cable tool 40 Reverse 7[�driven 1CQ Dug
� 7
✓
`� � / . f v �C���-C, 2[f Hollow Rod 5[]A1r 8(]Bored 11�
C'
� 3�Rotary 60�etted 90 Power Auger
Show exact loca[ion of well �
(in section grid �fth "X") Sketch map of well locatton 6. OBSTRUCTIONS ,
� Well obztructed� No
_ � _ _ _ _ j_ _. Ot�t�c�Clonnre�ved � 2 [f No (f obstructions cannot be
2
�� � L v rertaved, contact MDH
' ' ' -I- - E
M . _ _ , _ � before sealing.
` � , � T 7. USE
- - ' " " y.,�, �[JDomestic 4�Monitoring 80 Heat Loop
' ; _ ; ; I 2� Irrigation 50 Publtc 90 Industry
s
1 30 Test Well 6�Municlpal 1C[�Commerclal
• 1 .iL--i 7[]Air Cand1[laning 11�]
2. PA PERTY OWNER'S NAME Mailing Aadress if dlfferent than 8. LASING(S)
� property address indtcated above 1�'Black 4[��Threaded 7[]
� Y�
�`� / ` 2[�Galv. 5[�Nelded
`l? �'),L(,�� 30 Plastic 6�]Stainless Steel
HARDMES$ OF �7 ��=
3. FORMNTION LOG COIOR FORMATION FROM TO =1 ��• to � � ft.
If not known, indicate formation log from new well or nearby well. 1n, to ft.
9. SCREEN �,
�Screened well from� ft. t���I.. ft.
� . (I,` knoM�n)
�Open Hole from_ ft. to_ ft.
10. STATIL WATER LEVEL
����_ft. �below �above
� land surface Date Measured �� i�.
11. NELIHEAD COMPLETION
1�Pltless Adapter 4Q Found Buried
� Z� Basement offset �
30 Well Ptt
16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
12. GROUTING [NFORhV1TI0N
�Neat Lement 20 Bentonite �
Grout material�.-� �j;y.-c�[.; from/��-`Ltol=% ft. cu. yds�
13. NEAREST SOURCES OF CON7AMINATION
_ feet directton type
Well disinfected before sealtngl � Yes
14. DUMP �Removed �Not Present �
Type: 1[� Submersitrle 30 L.S. Turbine �Reciprocating
2[]Jet 40 Lentrifugal 5(��.i''_T��c�{�;�{�r
15. EXISTING WELLS (Please sketch locations of abandoned and
active wells fn remarks section or on back,)
Other unused well(s) on property? �Yes �i No
Abandoned: �Permanent �Temporary �]Not sealed
17. WATER VELL CONTRACTORS CERTIFICATION
This well was Seated under my jurisdiction and this report
is t ne to th�best of my knowledge and belfef.
� / rt
._- � , �; l�; �--
�z��` .•�t,.< ;� �_t
� Ltcensee Business Name �� License No.
Address � � ' - y�:'� : '�
. _ -- � .f. --s_
Signed "'/ i_ '-�= � ate / f.l .,L-
—��,',�.y =i f>: Dat //� / ti—�`�.L
OFFICIAL ABANDONED VELL RECORD (May be used for Property Transfer) naiue of.Drtller i �