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/�� ���, ��� �/��ATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED IrELL RECORD <br /> �. �a�Tioe of wc�� MINNESOTA UNIpUE wEll N0. <br /> (teave Alank 1f not known) <br /> County Name <br /> Henne in <br /> Township N�me Townzhtp Number Range NumDer Sectton No. Fractten 4. WELL DEPTH (completed) Date sealed <br /> N E ti ti o/ 5 <br /> Orono 11/.1 Sr 23W Mr 26 L��� .S�'� �'�� 1�0 ft. 0-3�-00 <br /> Numerlcal Street Addree�i anE Gl o! Mell locatton or Dlstance lrom Road 5. DRILLING METHOD (if known) <br /> IntersecNon 1� Cable tool a[J Reverse 70 Ortven 10�Dug <br /> 1585 6th Avenue �lorth, 'Long Lake, PMI 55356 zO Ha��aM Rae spa�� ep ea��e ��p <br /> 30 Rotary 60 Jetted 90 Power Auger <br /> ���S�or exact louttnn.nt..w�ll <br /> (in sectton yrid vtth "X") ��� �etch map of well lotaN on <br /> 6. OBSTRUCTIONS <br /> N Mell obstrutted�Yes � No <br /> _ i _ , _� Obstructlons removed(]Yes �]No If obstructtons cannot be <br /> ' ' � removed, contatt MOH <br /> M _ � � _I � E betore sealln9. <br /> � ; , ; j �. �sE <br /> - • • - - y� 1�DomesNc AQ Monitorlqg P�Heat Loop <br /> 1 ; ; I 2[� [rrigatlon 50 Publit 90 Industry <br /> ��_ . .,. _ � <br /> � 30 Test Well fi�Munlclpel ICQ Commercial <br /> S 7�Air Condltlontng 110 <br /> �—1 .i C� <br /> 2. PROPERTY 04NER'S NAME Mailing Address if different than 8. CASING(S) <br /> property address indicated aAove l�Black 0(�Threaded 7(] � <br /> George Levering �Galv. 50 Welded <br /> 30 Plastic 6[]Stainless Steel <br /> NARONESS OF <br /> J. FORMAT[ON LOG COLOR fORMATION FROM TO 3 in. to ft. <br /> If not kno�n, indfcate farmation log from new wel� or nearby well. 1n, to ft. <br /> 9. SCREEN <br /> �Screened well from_ ft. to _ ft. <br /> (1f known) <br /> �Open Hole from_ ft, to _ tt. <br /> 10. STATIC MATER LE4EL <br /> 9� ft. � below �above <br /> tand surface Oate Heasured 8—3�—8 8 <br /> 11. MELLHEAD COMP�ETION <br /> 10 Pttless Adapter �Found Buried <br /> - 2� Basement offset 50 <br /> 3�4e11 Pit <br /> 16. REMARKS, ELEVATiON, SOURCE OF OATA - CASINGS REMOVED. CASINGS PERFORATE�, ETC. <br /> 12. GROUT[NG INFORWIT(ON I <br /> 1[$�Neat Cement 2�BentanTte � <br /> Grout materi�l 3a bdC{S from+6��to�.10�t. cu. yds.l <br /> I1J. NEAREST S�JUP.CES OF CQHTAkSNA?ION <br /> _ teet dlrectton type <br /> uell dlsinfecteE before sealing? [] Yes <br /> 14. DUM7 �Removed � Not Present <br /> Type: 1[I Submersible �L.S. Turbine � Reciprocating <br /> 2�J Jet E�Centrlfugal 6[] <br /> 15. EXISTING MfLLS (Pleese sketeh loc�ttons of abandoned and <br /> aetive wells in remarks sectton ar on back.) <br /> Other unused welt(s) on OroDertyT �Yes � No <br /> Abandoned: []Permanent �Temporary �Not sealed <br /> 17. MATER MELI CONTRACTORS CERTIFiCATiON <br /> This Hell was sealed under my jurisdictton and th15 reDort <br /> is true to the bezt of my knovledge and belief. <br /> Stevens ��ell Drillin 271 4 <br /> L1ce e slne s ame Ltcense No. <br /> ��14� �:i��way 12 ;Vest <br /> aaa��s: �laple Plain P'�1 55359 <br /> siy�eei oac� 8-30-88 <br /> �.ice Rivers o,e� 8-30-88 <br /> qFFiCIAL ABANppNEO WELI RECORD (Nay be used Ior ProDerty Transfer) N�m� of Dr111�r <br /> ZllPGRf'AIIT: IZLd MITH DadD <br />