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• <br /> STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL- 1 MINNESOTA UNIQUE WELL NO. <br /> County Name -/ • <br /> (leave blank if not known) <br /> J I� <br /> Township Name Township Nu0Ser Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> /� o/ •^/� E 4 la of is ) ) <br /> I(24-..-- ---- <br /> /1 ..-" am /C S r d .J �) )/ ./ -7 C) ft. /rJ - 1 rte-- 61/ <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) <br /> Intersection 1Cable tool 40 Reverse 70 Driven 100 Dug <br /> 6 O / LL. / 20 Hollow Rod 80 Air 40 Bored 110 <br /> 30 Rotary 60 Jetted 90 Power Auger <br /> Show exact location of well <br /> (in section grid with "X") Sketch map of well location <br /> N 6. OBSTRUCTIONS <br /> Well obstructed Ries 0 No <br /> ;IC- - - - - - -- • Obstructions removedla Yes 0 No If obstructions cannot be <br /> (,L,,,,G'L' removed, contact MOM <br /> W - - - - • - - . -I- - E —A before sealing. <br /> - T 7. USE <br /> , 4.C. I�Domes'tic 40 Monitoring 80 Heat Loop <br /> 20 Irrigation 50 Public 90 Industry <br /> I <br /> , 1 � 3[j Test Well tU Municipal 1C0 Commercial <br /> t------1 SU--+ 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAMEE� Mailing Address if different than 8. CASING(S) <br /> ___c_./ ..-- property address indicated above 14Black 4pLThreaded 70 <br /> Cr 20Galy. 50 Welded <br /> ','.�- ` • 3L]Plastic 60 Stainless Steel • <br /> HARDNESS OF (' <br /> 3. FORMATION LOG COLOR FORMATION FROM TO J Tn, to s ft. <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> 9. SCREEN <br /> {aScreened well from,7)y ft. to°-7 0 ft. <br /> ��11 <br /> (If known) <br /> (9 J.?D 0 Open Hole from_ ft. to_ ft. <br /> 10. STATIC WATER LEVEL , <br /> 0 ft. (_below 0 above <br /> land surface Date Measured /...) -1.2- G 7e <br /> 11. WELLHEAD COMPLETION <br /> 10 Pitless Adapter 40 Found Buried <br /> 20,Basement offset 50 <br /> 30 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> I1 Neat Cement 20 Bentonite 30 <br /> Grout material from_to ft. cu. yds <br /> _ 1 <br /> - --� 13. NEAREST SOURCES OF CONTAMINATION <br /> 42 feet i:, - direction 6X•'Z--11t -, type <br /> Well disinfected before sealing? 0 Yes <br /> 14. PUMP f'.al Removed 0 Not Present <br /> Type: 10 Submersible 30 L.S. Turbine 1 Reciprocating <br /> [� 3 <br /> laget 40 Centrifugal 60 <br /> Ea 3 1 1991 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks section or on back.) <br /> Other unused well(s) on property? 0 Yes ANo <br /> Abandoned: 0 Permanent 0 Temporary 9 Not sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was sealed under my jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> /� 0 ?J 7 .6 <br /> 1t t�^ �/�tl.� L�� <br /> Licensee Business Name yJ License No. <br /> C7J- 3 o is(---i -e7��i <br /> Address '?-L�-/w`- 4-e 4. / <br /> Signed j�-f,.,.-,y -fi t�.Sf Date 1.2 .2.P 7/ <br /> k� � Date i -'' 9.'tName of Dr lie <br /> FFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) <br /> I1�Cy2T.1NT: PILE WITH DEED <br />