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STATE OF MINNESOTA DEPART'P4ENT OF HEALTH
<br /> . ' ABANDONED �HELL RECORD
<br /> 1. LOtATION OF VELL MINNESOTA UNIQUE WELL N0.
<br /> County Nama '
<br /> (lenve blank if not knorn)
<br /> Tornshlp Nama Townsht umbp� Range Numbe� SeeLion No. Fractlon 4. WELL DEPTH (eompletedj Date aealed �
<br /> � 7 '� a� � lo k�� � �6 d ,t. lo ��. �, �
<br /> Numarical Street Addrflas and Ctty of Well Loeation or Diatance from Road 5. ORILLING NETHOG (iP knoxn)
<br /> Inte�seetton • 1�Cabie tool 4�Reverse 7(]DMren 10[]Dug I�I
<br /> � O � � 2�Hollow Rod 5[]At� B[�Bored 110 i
<br /> Sh w exaet loeation of we11 3�Rotary 60 Jetted 9�Pawe�Auger �
<br /> (in settlon 9rid with •X'� Stetch map of we11 loeattan �
<br /> N 6. OBSTRUCTIONS
<br /> Yell obsLrvcted�1'ea � No
<br /> - � - - = • - �-•-� ObsLruetions �eawved 0 Yes [�No If obstructlons cannot be '
<br /> � � � � remored contact MOH
<br /> x _ _ '
<br /> � -'_ '+ _I'a _ E Defore sealing.
<br /> . , � ; T �. use �
<br /> � ,- '•; • ;- -� 4�:. 1�Doaiesiie 4�MoMtoring 8[a Heet Laop
<br /> ,,,. , .:,,_,�,,..: _ I 2L][rMgation 5�pubt ic 9�Indust�y
<br /> � � S � 1 30 Test Yell 6�Runlelpal 1CQ Commerctal
<br /> ' 1��----+ 7V Air Condittoning 1][]
<br /> 2. PR ERTY OIINER': NAME Nailing Address 1f different than , 8, CASIHG(5)
<br /> �� property address lndicated above �1aek 4�Threaded 1�
<br /> t
<br /> zQ c�t�. sp u.�aea
<br /> 3=]Plastit 617 SWlnleas Steel •
<br /> HARONE55 OF '
<br /> 3. FORHATION LOG COLOB FORMATION FROM TO ��^• to�ft.
<br /> If not known. indltate farmatton loq from new we11 0�nearby rall. 1n, to fC. -
<br /> 9. SCREEN '
<br /> . �Streened we11 }rom_ft. to__ft.
<br /> (If known)
<br /> ❑Opan Hole ' from_�fL. to�_ ft.
<br /> 10. STATIC y�ATER LEVEL
<br /> , �� tt.�baiow �above
<br /> . iend aurta�a Date Neesurad �
<br /> 11. WELIHEAD COMPlETION
<br /> 10 Pltiesa Adapter �Found Buried
<br /> �BasemenL offset '�
<br /> 3Q Yell P/t
<br /> 16. REMARKS, ELEYATIOM, SOURCE OF �ATA - CASINGS REMOVED, CASINGS PERFORATEO. ETC. �
<br /> . 12. G UTING INFOW4ATION
<br /> 1,(�Neat Cement 2�Bentonita �
<br /> �
<br /> Grout mata�lal C'O.YL�e�.�from o ft. cu. Yds
<br /> , 13. NEAREST SOURCES OF GONTAMINATIOM
<br /> , _ ieet ��rectian LYPe
<br /> Mell dlslnfeeted before sealingT�']Yes , II
<br /> 14. PUMP �Removed �NoL Present I
<br /> ' , Type: 1Q Submerstble 30 L,S. Turbtne �Retiprocating �
<br /> , �Jet a0 Centrifugai 6� •
<br /> ; � ��� _ 15. EXISTING NELIS (Please aketch laeattons oP abandoned and I
<br /> '� active welis tn remarks saction o� on Daek.)� �
<br /> �' Othe�unvaed wall(s) on prope�tyT �Yes �No '
<br /> ' I sy ,�� G,' a;� � Abandoned: C1 Permanent �Temporary []Not seeled '
<br /> . � z,, +-� U
<br /> 17. HA7ER MEIL CONTRACTORS CERTIFICATTON
<br /> This well was sealed de�my�urlsdietlon and this report
<br /> 1s true the Dest my knoNledge a e f.
<br /> t 1MA�' 4 �992 �✓' l� .�
<br /> ltcensee uslness Name Ltcense No.
<br /> . Addresa '
<br /> Stgn� - Date �
<br /> Date �
<br /> FFICIAI.ABAIVppNED YELL P.ECOItO (May be used for Proparty Transfer) Name of Dri a� V
<br /> ZXPC�TANTi PZLB WZTlf DBSD
<br /> ;.,`c^�i
<br /> - . � ��,d''.�P.-��
<br /> .,. ...,,. ..,� .._ . ,. . _ . ` - ' , .... ,. , ,,, . - . . , 'i;,�,t',:d'�"
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