HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTN
ABANDONE� NELL RECORD
1. �oC�Tton aF uEu MINNESOTA UNIQUE WELL N0.
County Name ,�` (leave blank if not known)
i
� `� / �
Townzhip Hame Township umb�r Range Number Section No. Fraction 4. NELI DEPTH (tampleted �ate�sealed
/:,l E k h o f y
�Y >
� � ft. j/
/ or � —/
/ �fsYi-c�— ( � s _� w>' --, ..S�' ..5.�„1 ��v U �' `-�
Numerical Street Address and City of Mell Location or Oistance from Road 5. �RILLING METH00 (if known) C
Intersectton � 1�Cable tooi 4�Reverse 7(]Driven 10[]Dug
3 � � � "' 2Q Hol low Rad 50 Air 8(]Bored 11�
Show exact lotation of well 30 Rotary 60 Jetted 90 Power Auger
(in sectton grld r1tA "X') Sketch map of well lotatlan
N 6. OBSTRUCTIONS
, Ne11 obstructed Q Yes �° No
- � - - : •- -� Obstructlons removed�Yes �No If obstructions cannot be
i �
� removed, contact MOH
M _ . _ _ . _I_ _ E before sealing.
_ :_ � : � T �. �sE
t � y..i. 1.�Domestlt 4n Monitarinn Af1 ue.t ���p
' , ' � 2�Irrigatton SQ Public 90 Zndustry
•-�. . ._... _.i.. __..
� S � 30 Test Well 6❑Munitlpal lt0 Cortmercfal
�---1 niL---i 7�A1r Condltloning 11[]
2.i�RT�R'S NAME Mailing Address 1f dtfferent than 8. CASING�S)
� property addresz indicated above 1�Black 40 Threaded 7[]
� 'i'��.L 2[�Galv. 5[�Melded
30 Plastic 60 Stalnless Steel
HAR�NESS OF
3. FORMATION LOG COLOR FORMATION FROM TO � in, to��ft.
If not known, lndicate formatlon log from new well or nearby well, 1n, to ft.
9. SCREEN
�Screened well from_ ft. to ft.
(If known)
�Open Hole fram_ ft, to _ tt.
10. STATIC�LEVEL
�_ft. � below �above y�//�y_
land surface Date Measured 5������" (
/
11. WELLHEAO COM�LETION
10 Pltless Adapter �Found Buried
2�'�Basement offset �
30 Well Pit
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASIN6S PERFORATE�, ETC.
12. GROUTING INFORW�TIOk
1�Neat Cement 2[]Bentonite �
Grout material �f�,^.•-.,�_fro��to U ft. cu. ydz
— __ — �
13. NEA$�$7 SOURCES E COIi7AMINATION n '
,� feet � dlrectton `.�i/�{�f/�,Q type
Metl dlsinfected before sealingt [] Yes
14. PUMP ,�Rertaved �Not Present
Type: 1[� Submersible 3� l,S. Turbine � Reciprocating
, 2�I Jet 40 Centrifugal 60
r
15. EXISTING WELLS (Please sketch locattans of abandoned and
active wells tn remarks section or on 6ack.)
. Other unused wall(s) an property? �Yes �''No
- Abandoned: �Permanent �Temporary �Not sealed
17. WATER WELL CONTRACTORS CERTIFICATION
Th1s Hell was sealed under my ,jurisdlction and this report
�} *,�..,;_;; is true o the be of �ny knowledge and eltef.
���Pa\� _ , _ `'�/
� .�
Llcensee Bustness ame Ltcense No.
Address
SigneE�j� / Oate -
! �
Date
OFFICIAI ABANDONED WELL RELORO (May be used for Greperty Transfer) ame of Dr111er "
IlIPC�TART; PZLS WZTE DSSD _ .-��