HomeMy WebLinkAboutAbandoned WellSTATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED WELL RECORD
1. LOCATION F WELL
T:�:
p Name Township Number Range Numbs J / / J � E 3 !
r i Street Address Ann city of cell Location or Distance Irom goal
Show exact location Of roll
(in Section grid rich
N
Jan.
ti
Sketch map of well IUkka /
V1Y !
Sad �f
I
MINNESOTA WELL N0.
(leave Clank k if II not not known)
//o
ft. I
3 - /J' q,
5. DRILLING METHOD
(if knom)
let n4Ul
LEI Elsie tool
C[( Reverse
J(] Driven IOF, Dug
20 Nonov Rod
S❑ Air
P❑ Bored 110
1B Rotary
5❑ JettrJ
PEI Power Auger
Ren oss tructed ®Yet ❑ No
OGS this: [ions removed a Yet ❑ No If Dos t rust i one cannot be
moved, Pont," NEW
before sealing.
?. USE
1WI Domestic 1❑ Monitoring F❑ Heat Loop
20 Irrigation E Public 9C Industry
30 Test Well 60 Munlepal 1LO COneercial
T❑ Air Conditioning 110
2. PROPERTY OWNER'S NAME
Mdili ng
Add re ll if d1 If e refat than
P.
let n4Ul
property
cadres: indicated "dove
I® Black C❑ Threaded 1❑
k � '
'
20 Galy. So Welded
no Plastic 6[3 Stainless Steel
HRRONESS of
In t0 /O
3. FORMA, TICS LOG
COLOR
"WITION FROM To
If not known, indicate
formation lag
from new well or nearby well.
in. to It.
❑ Screened well from // OJ
(If known)
❑ Gpen Hole from _ ft. to ft.
rt.® below C] above
surface fate Date reamred
REW[RMS,
CASINGS PERFORATED. ETC.
11. WELLHEAD COMPLETION
lip P1 t le ss Adapter 10 Found Buries
20 Basement offset S❑
30 Well Pit
3® Neat Cement 20 Eratonits ;]
Grout menrial / C/ fru l It. cu. leaf
13. NEAREST SOURCES OF CONTAMINATION
_e RE feet �� direction ,.1�1.Q(� type
Well disinfected before feAling? ® Tee
lo. PUMP aRenoved [:I Not Present
Type: 30 Submersible 30 L.S. Turbine 0 Reciprocating
2❑ Jet fl Centrifugal 60
IS. EXISTING YELLS (Please Sketch locations of abandoned and
aCtiW .11A a M1Yrks section of On Meek.)
Other unund wll(s) on Property? Q Tea 4a No
,,donee: ❑ Penall ❑ Temporary ❑ Not Sealed
WELL CONTARCT0R9 CERTIFICATION
This .11 Was Haled Yoder My filrisdiction AIM this rePOrt
is true to t".t of fay k lad" rid belief.
Ad
Signed
IFFICHL A4aE0NE0 WELL RECORD (My be used for Property Treasf I)
JOQM'Lls Jef" IFFIV CROWD