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STATE OF MINNESOTA DEPARTMENT Of HEALTH <br />ABANDONED WELL RECORD <br />LOCATION OF su <br />County Now 1Jyt/3�! ,.Nti <br />TewsMp NM Towson Number Range Num0ar Section No. Fwtloa a. <br />E k k of ii <br />Numerical Street Address and City of Well Location or Distance from Roof <br />Intersoctlon/�� <br />Show nct 1Katlea of well <br />(L sactton pfd with '1a) Sketch map of well location <br />1f <br />®m®w <br />ME <br />MEIN <br />V—tatV <br />?. ►rAptm oma*s NAPE mmiting Address If different than <br />property address lndfcated, ove r� <br />NAADNtSS Of <br />S. FOWTION LOG COLOR FOWTtON rRON TO <br />If Mt kssawa. Indicate formation leg free new well or nearby well. <br />. SOURCE OF DATA . CASINGS KMDYEO. CASINGS ►ERFORATED. <br />MINNESOTA UNIQUE YETI NO. <br />(leave blank If net knew) <br />e soled <br />l G� ft. l C <br />S. ORILLIhJ MET1100 (if know) <br />1® Cable tool 40 Reverso 70 DrIvM 100 oug <br />20 No11ow Rod SQ Air I10larod 110 <br />30 Rotary 40 Jetted C huger Auger <br />S. OGSTNKTIONS — <br />Wa11 obstrwctNle Too ❑ me <br />ONtruttiems removed WToo ❑ No If oMtrwttIWS cannot be <br />renv". contact Mel <br />bf ,re sealing. <br />7. USE <br />1M Domestfc <br />�-�i <br />Q NMItoring 40 Most LO" <br />20 Irrigation <br />![3 ►ub71c 10 lo"Stry <br />30 Test Wall <br />10 APICIpel ICC Camw cIaI <br />70Air Cenditloning IIC <br />G. r.ASING(S) <br />IM $lack <br />4M ThrMded 70 <br />70 Gaiv. <br />SQ Molded <br />30 Plastic <br />do Stalmless SWi <br />Viy <br />In. to r J`_ft. <br />In. to ft. <br />9. SCREEN .�' _ <br />[] Screened welt from � ft, to%f ft. <br />(I! knows) <br />❑ Open Net• from _ ft. to _ ft. <br />10. STATIC R LEVEL <br />0 ft. 0 below ❑ above <br />lend swrfaco Date Measured <br />11. WLLIMEA0 CO1PLiTION <br />113 Htlese AQata► C found Gwried <br />70 Easameet offset 10 <br />313 well Pic <br />10 Neat Caamet 10 wotdMte 30 <br />Grout material fmo; I`tk." !. cu. yds <br />11. NEAREST SOURCES Of CONTAMINATION <br />feat_ direction Lelci,type <br />Wall disinfected before sealing? ® Two <br />14. NW 0 Raved ❑ Not Present <br />Type: 10 Submersible 0❑ L.S. Turbine 10 Reclpoeatimg <br />20 Jet Q camtrifwtat Q <br />1S. EXISTING YELLS (►lgse Sketch tecatieno of aMmMded and <br />active will in re"s section or on back.) <br />Other unufad MIX($) On property,❑Tel Ile <br />AbandoRed: ❑ ►ermsneat ❑ Tamorary ❑ Not sw*o <br />17. WATER WILL CONTRACTORS CERTIFICA'IOII Y <br />This wall was sealed uoar my Jurisdiction ant w1v report <br />�. true to the be t of my knowlad9a and wi let <br />C% � <br />licanf WfiMil Nano L1tfaM N0. <br />Address <br />Sfgned l f/<... T' ate <br />Date .) 7 <br />OFICIAL AGFNNINED WELL RECORD (Way to used for Property Trinafar) N.ma q1 Ors War <br />11111PeONIlAffs FZLE IR21 OQD I _ <br />