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STATE OF MINNESOTA DEPARTMENT OF HEALTN <br /> ABANDONED WELL RECORD <br /> 1. �otaiIOn oF uEll MINNESOTA UNIQUE WELL N0. <br /> County Name � ��eave blank 1f not known) <br /> )r'L� ,iG. <br /> Township Hame Townsh'- Numbe.r Range Number Section No. Fraction 4. NELI DEPTH (compteted) Date sealed <br /> �1 , r_ / E k k of y <br /> � N ^ <br /> ` ^ � �'�l ��r !l'>�.9L- I .,� � � . � f t. � t/J `i ) <br /> ,,���. �; s ��, .. w <-,�� �'��>��,,;�.. j����,��- �: ; ; —;/��., <br /> Numerital Street Addresz arid Lity of l�ell Location or Otstante from Road � 5. �RILL7NG METHO� (if known) � <br /> Incersection /� 1�Cable tool 40 Reverse 7[�driven 1CQ Dug <br /> � 7 <br /> ✓ <br /> `� � / . f v �C���-C, 2[f Hollow Rod 5[]A1r 8(]Bored 11� <br /> C' <br /> � 3�Rotary 60�etted 90 Power Auger <br /> Show exact loca[ion of well � <br /> (in section grid �fth "X") Sketch map of well locatton 6. OBSTRUCTIONS , <br /> � Well obztructed� No <br /> _ � _ _ _ _ j_ _. Ot�t�c�Clonnre�ved � 2 [f No (f obstructions cannot be <br /> 2 <br /> �� � L v rertaved, contact MDH <br /> ' ' ' -I- - E <br /> M . _ _ , _ � before sealing. <br /> ` � , � T 7. USE <br /> - - ' " " y.,�, �[JDomestic 4�Monitoring 80 Heat Loop <br /> ' ; _ ; ; I 2� Irrigation 50 Publtc 90 Industry <br /> s <br /> 1 30 Test Well 6�Municlpal 1C[�Commerclal <br /> • 1 .iL--i 7[]Air Cand1[laning 11�] <br /> 2. PA PERTY OWNER'S NAME Mailing Aadress if dlfferent than 8. LASING(S) <br /> � property address indtcated above 1�'Black 4[��Threaded 7[] <br /> � Y� <br /> �`� / ` 2[�Galv. 5[�Nelded <br /> `l? �'),L(,�� 30 Plastic 6�]Stainless Steel <br /> HARDMES$ OF �7 ��= <br /> 3. FORMNTION LOG COIOR FORMATION FROM TO =1 ��• to � � ft. <br /> If not known, indicate formation log from new well or nearby well. 1n, to ft. <br /> 9. SCREEN �, <br /> �Screened well from� ft. t���I.. ft. <br /> � . (I,` knoM�n) <br /> �Open Hole from_ ft. to_ ft. <br /> 10. STATIL WATER LEVEL <br /> ����_ft. �below �above <br /> � land surface Date Measured �� i�. <br /> 11. NELIHEAD COMPLETION <br /> 1�Pltless Adapter 4Q Found Buried <br /> � Z� Basement offset � <br /> 30 Well Ptt <br /> 16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING [NFORhV1TI0N <br /> �Neat Lement 20 Bentonite � <br /> Grout material�.-� �j;y.-c�[.; from/��-`Ltol=% ft. cu. yds� <br /> 13. NEAREST SOURCES OF CON7AMINATION <br /> _ feet directton type <br /> Well disinfected before sealtngl � Yes <br /> 14. DUMP �Removed �Not Present � <br /> Type: 1[� Submersitrle 30 L.S. Turbine �Reciprocating <br /> 2[]Jet 40 Lentrifugal 5(��.i''_T��c�{�;�{�r <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells fn remarks section or on back,) <br /> Other unused well(s) on property? �Yes �i No <br /> Abandoned: �Permanent �Temporary �]Not sealed <br /> 17. WATER VELL CONTRACTORS CERTIFICATION <br /> This well was Seated under my jurisdiction and this report <br /> is t ne to th�best of my knowledge and belfef. <br /> � / rt <br /> ._- � , �; l�; �-- <br /> �z��` .•�t,.< ;� �_t <br /> � Ltcensee Business Name �� License No. <br /> Address � � ' - y�:'� : '� <br /> . _ -- � .f. --s_ <br /> Signed "'/ i_ '-�= � ate / f.l .,L- <br /> —��,',�.y =i f>: Dat //� / ti—�`�.L <br /> OFFICIAL ABANDONED VELL RECORD (May be used for Property Transfer) naiue of.Drtller i � <br />