HomeMy WebLinkAboutwell info STATE OF MIN"�SO7A DEPARTMENT OF HEALTH
ABANDONED WELL RECORD �
i. �oc�rton av uE�� MINNESOTA UNIQUE WELL N0.
(leave blank 1f not known)
County Name ��
Tornship Name Township Number Range Number Section No. Fraction 4, uELL DEPTH (complete!j Date sealed
16� E k k of 4
�lr/�_ / �-� �s �� � � / �C, rt. ! +� " 3 / — ' /
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Numerital Street Address and City of Well Location or Distance from Road 5. DRIILING METHOD•(if known)
Incersection I�Cabte tool 40 Reverse 7[]�riven lOQ Oug
� � o � _�t��'��� lilic-✓v % �Hollow Rod 5�A{� �Bored 11(]
3�Rotary 6�Jetted 9�Power Auger
Show exact location af wetl
(in sectton grid vlth "X") Sketch map of well location � 6. OBSTRUCTIQNS
N Well obstructed�Yes � No �
_ � _ _ _ _ ._ _� Obstructlons removed�Yes �No If obstructions cannat be
� � � removed, contact NOH
W - ' - - ' - y -I- ` - E � before sealiny.
J
- _ :_ : :_ _� T �� �' '. °SE
;� yl.�.
� � 1�Domestic 4�Monitoring 8�Heat Loop
2i] Irrigation �]Pubitc S[] Industry
�..�_ `1l�
' ' ' 1 ! "J 30 Test Well 60 Municipal 1C(]Commercial
� 1 SL 7�Air Condltianing 110
Z. .'ROPERTY OWNER'S NAME Mailing Address if different than 8. CASING(5)
j I Droperty address indicated above 1�Black 4(�Threaded 7(�
.� ,
`� �r� ,Jfi1���.�-.,,..%'L � 2�Galv. 50 Welded
� 3I]Plastic 6j]Stainless Steel
HARONESS OF ,� 1n. to � � ft.
I 3. FORHATION lOG COLOR FORMATION FROM TO
if not known, indicate farmation log from new well or nearby well. 1n. to ft.
9. SCREEN
(,a'Screened r+ell from 7 J ft. to�(�t.
�7 P (I° known)
L� �7 � �Open Hole from_ ft. to_ ft.
i 10. STATIL TER LEVEL
���ft.� below �above
land surface Date Measured �v '3�-
11. WELLHEAD COMPLETIOH
10 Pitless Adapter 40 Faund Buried
2�BasemenL offset �
30 Nell Ptt
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
12. GROU??NG INFORMATION I
�Neat Cement 2(�Bentonite �
Grout material ,3 from�to (�ft. cu. yds�
! � 13. NEAREST SOURCES Of CONTAMINATION �.
_LDfeet i...� directlon f��+-�— type
{ Mell disinfected before sealing7 �Yes
1
.�A N � �v"� 14. PUMP �Removed � Not Present
Type: 1[1 Submersible 30 L.S. Turbine �Reciprocating
( i 2�Jet 40 Centrifugal 60
15. EXISTING WELLS (Please sketch locations of abandoned and
active wells in remarks zection or on back.)
Other unused well(s) on property7 �Yes �No
Abandoned: C1 Permanent �Temporary �Not zealed
I 17. 'dRTER WELL CONTRACTOR5 CERT(FICATION
This well was sealed under my jurisdiction and this report
is true to the best of my knowledge and belief.
t � �i�-(� / „�7� � �/ �
LiceCsee�uslnes�Name ` `��ice��No.
- Address '�y�L--- • �----. �
J• ' �
Signed _L� - �, . - -� �ate I 1 - 3 /
i
�L/t--� • �ate �J /- "r'7
FFTCIAt. ABArippXEO 'afLl RECORD (May be used for Property Transfer) �ame of D ilit ,
Zl'yL'CRT.l1172r F.TLS WZTII DSBU I