HomeMy WebLinkAboutWell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION OF IIELL MItJNESOTA UNIQUE WELL N0.
(leave b'ank tf not known)
County Name �j � �
r y�,
7ownst�ip Name Township umber Range Number Section No. Fraction 4. WELL OEPTH (completed) Date sealed
� E : : of ;
�ir��� � r d ? dl / � I J "� ft. � '- �l ' �
S J C'J � � o�
�merical S[reet tiddresz and City of Well Location or �istance �-.�n Road 5. ORILLING METHOD (if known)
IIntersection , i 10 Cablr tool 4[�Reverse 70 Driven 10[�Dug
� � � �� '/�` w� r^ O 2� Hollow Rod 5[�Air 8�]Bored 110
iY� ��i`
30 Rotary 60 Jetted 9�Power Auger
Show exact location of well
(in settion grid wfth "X") SRetth map of well location 6. OBSTRUCTIONS
, N {� . Well obstructed�Yes � No
_ � _ _ _ ,_ _� �n t�� Obstructions removed�Yes �No If obstructions cannot be
' ' i y/1 removed, con[act MDH
' -I- - E ' ` before sealing.
w - - - - � - -
` ; , ; j �. �sE
- - • -- -- 4,� 1�Domestic 40 Monitoring 80 Heat Loop
; ; i ! � lNf� 20 Irrigation 50 Public 9� Industry
30 Test Well 6�Munictpal 1C(]Commercial
I �-1 SL- --� i• ' ��t� —_ 7�Air Conditioning ii�.
2. PROPERTY 01JNER'S NAME Mailing Address if different than 8. CASING(S) �
�,A � � property address indicated above l�Black 4�Threaded 7[]
X�Ll
� 2[�Galv. 5�Welded
� 3�Plastic 60 Stainless Steel
HARDNE55 OF �_� .2 � �J� ft.
I 3. FORMATION lOG CDLOR FORMATION FROM TO tn. to
IIf not knovn, indicate formation log from new well or nearby well. in. to ft. _
9. SCREEN
�Screened well from�,�. to�t.
(I,` knoM�n)
I ��'� ❑Open Hole from ft. to ft.
t-- — —
30. STATIC WATER LEVEL
,� U ft.� below []above
� land surface Date Measured ' ��'
11. WELLHEAD LOMPlETION
1(]Pitless Adapter 4�Found Buried
2[�BasemenY offset s�
� 3[�Well Pit
16. REMARKS. ELEYATION, SOURCE OF DATA - CASINGS REMOVE�, CASINGS PERFORATED, ETC.
12. GROUTING INFORMATION
1�Neat Cement 2�Bentonite �
Grout material 7� frortr�t/�to� ft. cu, yds
I 13. NEAREST SOURCES OF CONTAMINATION �
r�� feet �_ direction � -`., type
uell disinfected before sealing? � Yes
�{� O 14. PUMP �Removed �Not Present
0 �O�j Type: 1[� Submersible 3�L.S. Turbine ;� Reciprocating
�\C� 2�Jet G�Centrifugal fi�
\%
15. EXISTING WELLS (Please sketch locations of abandoned and
Q�� active wells in remarks section or on back.)
� '"i�l��!�y Other unused well(z) on property? �Yes � No
2 Abandoned: �Permanent �Temporary �Not sealed
���
17. WATER WELL CONTRALTORS CERTIFICATION
This well was sealed under my jurisdittion and this report
is true to the be�5t of my knowledge and belief.
� . � � �l � J 7� 7 t0
i
Llcensee Business Nam License No.
�_
Address
� Signed � Oate ��/�
_ �/�--� Date - l-�J
FFICIAI ABANDONED uELI RECOFD (May be used for ProDerty Transfer) Na�Ae of ril�ler
I.�CY2TAIVT: PZLE WZTH DESD