HomeMy WebLinkAboutwell info /�� ���, ��� �/��ATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED IrELL RECORD
�. �a�Tioe of wc�� MINNESOTA UNIpUE wEll N0.
(teave Alank 1f not known)
County Name
Henne in
Township N�me Townzhtp Number Range NumDer Sectton No. Fractten 4. WELL DEPTH (completed) Date sealed
N E ti ti o/ 5
Orono 11/.1 Sr 23W Mr 26 L��� .S�'� �'�� 1�0 ft. 0-3�-00
Numerlcal Street Addree�i anE Gl o! Mell locatton or Dlstance lrom Road 5. DRILLING METHOD (if known)
IntersecNon 1� Cable tool a[J Reverse 70 Ortven 10�Dug
1585 6th Avenue �lorth, 'Long Lake, PMI 55356 zO Ha��aM Rae spa�� ep ea��e ��p
30 Rotary 60 Jetted 90 Power Auger
���S�or exact louttnn.nt..w�ll
(in sectton yrid vtth "X") ��� �etch map of well lotaN on
6. OBSTRUCTIONS
N Mell obstrutted�Yes � No
_ i _ , _� Obstructlons removed(]Yes �]No If obstructtons cannot be
' ' � removed, contatt MOH
M _ � � _I � E betore sealln9.
� ; , ; j �. �sE
- • • - - y� 1�DomesNc AQ Monitorlqg P�Heat Loop
1 ; ; I 2[� [rrigatlon 50 Publit 90 Industry
��_ . .,. _ �
� 30 Test Well fi�Munlclpel ICQ Commercial
S 7�Air Condltlontng 110
�—1 .i C�
2. PROPERTY 04NER'S NAME Mailing Address if different than 8. CASING(S)
property address indicated aAove l�Black 0(�Threaded 7(] �
George Levering �Galv. 50 Welded
30 Plastic 6[]Stainless Steel
NARONESS OF
J. FORMAT[ON LOG COLOR fORMATION FROM TO 3 in. to ft.
If not kno�n, indfcate farmation log from new wel� or nearby well. 1n, to ft.
9. SCREEN
�Screened well from_ ft. to _ ft.
(1f known)
�Open Hole from_ ft, to _ tt.
10. STATIC MATER LE4EL
9� ft. � below �above
tand surface Oate Heasured 8—3�—8 8
11. MELLHEAD COMP�ETION
10 Pttless Adapter �Found Buried
- 2� Basement offset 50
3�4e11 Pit
16. REMARKS, ELEVATiON, SOURCE OF OATA - CASINGS REMOVED. CASINGS PERFORATE�, ETC.
12. GROUT[NG INFORWIT(ON I
1[$�Neat Cement 2�BentanTte �
Grout materi�l 3a bdC{S from+6��to�.10�t. cu. yds.l
I1J. NEAREST S�JUP.CES OF CQHTAkSNA?ION
_ teet dlrectton type
uell dlsinfecteE before sealing? [] Yes
14. DUM7 �Removed � Not Present
Type: 1[I Submersible �L.S. Turbine � Reciprocating
2�J Jet E�Centrlfugal 6[]
15. EXISTING MfLLS (Pleese sketeh loc�ttons of abandoned and
aetive wells in remarks sectton ar on back.)
Other unused welt(s) on OroDertyT �Yes � No
Abandoned: []Permanent �Temporary �Not sealed
17. MATER MELI CONTRACTORS CERTIFiCATiON
This Hell was sealed under my jurisdictton and th15 reDort
is true to the bezt of my knovledge and belief.
Stevens ��ell Drillin 271 4
L1ce e slne s ame Ltcense No.
��14� �:i��way 12 ;Vest
aaa��s: �laple Plain P'�1 55359
siy�eei oac� 8-30-88
�.ice Rivers o,e� 8-30-88
qFFiCIAL ABANppNEO WELI RECORD (Nay be used Ior ProDerty Transfer) N�m� of Dr111�r
ZllPGRf'AIIT: IZLd MITH DadD