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4���� .. .. . _.. .�..... <br /> STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED NELL RECORD <br /> i. �oCArIOH oF uE�� MINNESOTA UNIQUE WELL N0. �- <br /> _ (leave blank 1f not known) � � <br /> Coun,y .4am! <br /> ,p��- .�{� <br /> Townsnip Name Township N mcer Range Number Section No. Fraction 4. WELL OEPTH (completed) Date seAled <br /> N E h h of y <br /> I �"1��.�`'— l l 7 Sr � .� yr � /CI ` ft. /l } L� 7s7 <br /> i .Yumer�cal S[reet Addresz and City of ','ell Location or �istance from Road 5. ORILLINf, METH00 (if known) � <br /> � :ntersection . <br /> I 1�]Cable tool a�Reverse 70�riven lOQ Dug <br /> ' / (, ) � /� , � 2[] Hollow Rad 5[�A1r 8�Bored 11 I <br /> '� �J 7 �T L / !/L '1.��� ��G•�•L•i.-C �.=i. • ❑ <br /> Show exacc locatton of well <br /> 30 Rotary 6�Jetted 90 Power Auger <br /> , ;in se;tion qrid with "X"j �� Sketch map of well location <br /> 6. OBSTRULTIONS <br /> � Well abstructed�}'Yes � Na <br /> i _ � _ _ . ._ _.. j 1 — Obstructlons removed�Yes �No If obstructions cannot tre <br /> i I .�� removed, contact MOH <br /> y _ _ _�_ , _ � _�_ � _ E ��� � before sealing. <br /> . i i . � . i : i � i 7. USE <br /> j- ' �, ' � -i ' y +i, l�Domesttc CQ Monitoring 8�Heat Loop <br /> � _��7�x� 20 Irrigation 5(]Pub11C 9� Industry <br /> ;_ ;_ ., ;_ ., . _... 1 �� <br /> 30 Test Well 6�Municipal 1C0 Commercial <br /> $ <br /> �--1 riL— 7u Air Gondittoning 11(__j <br /> : 2. ?ROPERTY OWNER'S NAME Mailing Address if dlfferent than 8. CASING(S) <br /> i Droperty address indicated above 1�Black 4�Threaded 7[, I � <br /> �,D�� /{�`V.:�,,,,,,L 2[�Galv. 5Q Welded i <br /> i�`� 6! <br /> 3L]Plastic 6�]Stainless Steel <br /> j NARDNESS OF � ` <br /> � 3 �ORMATION lOG LOLOR FORMATION FROM TO �n. to /�d J ft. <br /> i I <br /> .f not knovn, indicate formation log from new well or nearby well. 1n. to ft. <br /> I <br /> I I <br /> ' , 9. SCREEN <br /> � �]Screened wel l from l v�ft. to��� ft. <br /> (If known) <br /> � �ODen Hole from_ ft. to _ ft. � <br /> ` �L= �f I I V 10. STATIL WATER LEYEL <br /> I `�.`'' ft.�below [�above <br /> ' Tand surface Oate Measured ��, 3 c��- J� <br /> I <br /> I 11. uELIHEAD LOMPLETIOH <br /> I �'Pitless Adapter 4❑Faund Buried i <br /> � 20 Basement offset `{� � <br /> I 30 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVE�, CASINGS PERFORATED, ETL. <br /> � 12. GROUTING INFORMATION � <br /> I�Heat Cement 2�BentoMte � <br /> I� Grout material fra��d to� ft. cu. yds <br /> i <br /> � — —�, <br /> I � 13. N�Rq�ST SOURCES OF CONTAMINATIOk ^ <br /> J feet ��� <br /> i _ � directton Z„�r��c.—,_ type <br /> � Nell dlsinfected before sealingt,0 Ye: <br /> I <br /> l4. PUMP �Removed �Not Present <br /> I <br /> iTyDe: 1[� Submersible 30 L.S. Turbine � Reciprocating I <br /> � --- 2�Jet 4Q Centrifugal 6[� <br /> I �� ��. 15. EXISTING WELLS (Please sketch locatlonx of abandoned and <br /> � � � active wells in ttmarks section or on back.) <br /> . - �-�- Other unused well(5) on property7 �Yes � No <br /> Abandoned: �Permanent �Temporary �Not sealed � <br /> I <br /> i1. 'aATER WEIL CONTRALTORS CERTIFICATION i <br /> _., — This well was sealed under my jurisdiction and this report <br /> is true,7to the best af my knowledge and belief. <br /> DEC � A�.cAa�' � E`� -.0 ��.i� d...�..� � �7 <br /> Ltcensee Business Name 'Ltcenye No. <br /> . ` x+-�� '� - <br /> AddreSs � "v ,�1.4 <br /> Signed , �-�3'� _ -_/ Date / ��<t v %2 <br /> � r <br /> � Date -�J <br /> FFICIAI ABA11ppNE0 YELL RECORD (May be used for Property Transfer) me of Drtller� <br /> ZIlPQtTiIlIT: PILS WZTH OdSD <br />