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STATE OF MINNESOTA DEPARTMENT OF HEAL7H <br /> � ABANDONED NELL RECORD <br /> i. �ocArcON oF �+Eu MINNESOTA UNIQUE WELL N0. <br /> � (leave blxnk tf not known) <br /> tounty Nav�e <br /> Township Name Township mber Range Number Section No. Fraction 4. WELL DEPTlI (completed) Date sealed <br /> V 1 '�1.�v W / ( �� � 3 r � k k of k� �� ft. �� r- 6� '- < � <br /> ("J <br /> Yumerical S[reet Address and Ctty of Well Location or Distance from Road 5. DRILLIN6 METHOD (if known) <br /> Ir,tersection 1[]Cabla tool 40 Reverse 7[�Oriven 10[�Dug <br /> i �� O�` 2�Hollow Rod 5[�A1r 8[(Bored 110 <br /> 3�Rotary 6[,]Jetted 9�Power Auger <br /> SAow ezact location of weil <br /> (tn zectton grid with "X") Sketch af tatton 6. OBSTRULTIONS <br /> N Nell obstructed�Yes � No <br /> _ � _ _ _ ._ _� ��v�J Obstructions rem�ved�Yes �No If obstructions cannot be <br /> � � � removed, contact MON <br /> ' � � � � before senting. <br /> ►+ - ; - : -. -I- , - �� <br /> . , � , � T �. �5E <br /> ' `' ' y 1�Domestic 4�Monitoring 8(]Heat Loop <br /> •-h-- r_______________.._. <br /> I <br /> ' ; _ ' ; � �7 2[�Irrigation 5[�Public 9r Industry <br /> u J v 3[j Test Well 6�Munitipal lOL Commertial <br /> $ <br /> r--1 „�U--� 10 Air Conditioning 11[] <br /> 2. PROPERTY OWNER'S NAyE M iting Address if different than 6. CASING(S) � <br /> ��avl� property address indTcated above 1�Black 4�Thr:aded 7[] <br /> //� 2�j Galv. 5[J Welded <br /> �� 3�Plastic 6�Statnless Steel � <br /> HARDNESS OF � �n, to�_ft. <br /> 3. FORMATION LOG COLOR FORMAT(ON FROM TO <br /> If not known, indicate formation log from new well or nearby wetl. 1n. to ft. <br /> 9. SCREEN <br /> � �Screened welt from���ft. to�ft. <br /> (If known) <br /> �Open Hole from_ft. to_ ft. <br /> ~ cJ 10. STATI MATER LEYEL <br /> ' �ft. �below (]abave <br /> land surface Date Measured .�—�- �� <br /> 11. 41ElLHEAD COMPLETION <br /> 10 Pitless Adapter 40 Found Buried <br /> Z[f 8asement offset � <br /> �41e11 Pit <br /> 16. REMARKS, EIEYATION, SOURCE OF DATA - CASINGS REMOYED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> � I�Neat Cement 20 Bentonite � <br /> � Grout material � from�to� ft. cu. yds <br /> 13. NEAREST SOURCES OF CONTAMINATION <br /> �C/ feet _�� direct/on " _type <br /> D �� Well disinfected before sealing7 � Yes <br /> ��(� Q <br /> �On,.,� 14. PUMP �Removed '�Not Present <br /> L7 UL� <br /> Type: 1[I Submerslble 3� L.S. Turbine � Reciprocating <br /> 2�Jet 40 Centrifugal 60 <br /> ��� 15. EXISTiNG 41ELL5 (Please sketch locations of abandoned and <br /> active y+ells in remarks section or on back.) <br /> 2 �9�� Other unused we11(s) on property7 �Yes � tla <br /> � - , A6andoned: C1 Permanent �Temporary [�Hot sealed <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was Sealed under my jurisdiction and this report <br /> is true to the b t of my knowledge and belief. <br /> �_ .� c�� � � � <br /> Llcense Buslness Name � ce se No. <br /> Address <br /> Signed �ate �� 7 <br /> Date "� '-� <br /> FFICIAL ABANDONED 41ELL RECORO (May be used for �roperty 7ransfer) Name Dr1 er <br /> IXPQRTAIVT: PILB p7TS DdSD <br />