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.�, ,. .. ,�, �A.,� . ,.� �._ . . .,� .a. .-_ . � __. m �..�� .:,� ,..,,�. �,�,.. _: �;� . . WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 6 5 5 0 5 3 Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl. �,. �,. 163 1-17-01 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug ❑ Auger �Ftotary ❑ Jetted Show exact location of well in section grid with"X'. Sketch map of well location. ❑ _ Showing property lines, - f i .. ,,,,,�oads and buildings. DRIL�ING FLUID WELL HYDROFFACTURED? �;YES �NO i i N � � �-��""� super ��l�x FROM__ ft.to ft. - -� -�- -i- -�- USE ❑ Monitoring ❑ Heating/Cooling i i i i ❑ Domestic ❑ Communi PWS -� �- �- � � ��'~.._-"� Irrigation ry ❑ Industry/Commercial � f] Noncommunity PWS ❑ Remedial w i ' I E T � M ��_� Emiron.Bore Hole ❑ Dewatering ❑ ___ _ ! � —, � r '/plMlle � � �'� CASING Drive Shoe7 �Yes ❑ No HOLE DIAM. _i i _L_ _i_ � a��,�'Steel �Threaded — ❑ Welded— �- -�- � � Cl Plastic ❑ S V1 F1 �i Mile—� ^�'•----•�� '.�'rr � � � CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME __�__in.to I 5 3 ft. Ibs./ft. ��p�� Albrecht Irti�;ation Desi�n _---��.to-- h. �bs�h. �__,�.�o�� Property owner's mailing address if different than well location address indicated above. --._ _in.to fl. __._____Ibs./ft. __in.to ft. 1408 W C t y Rd C SCREEN OPEN HOLE Rosevilie, I�IN 55113 Make Jo_n D from n.to n. Type sta-inles�s �-tee� —Diam. __ .. SIoUGauze____�11'1 Length 1� __ Set between �_._ _ ft.and��R. FITTINGS: r c OI STATIC WATER LEVEL l�� F. Jl d WELL OWNER'S NAME ft.�'below ❑ above land surface Date measured ..._. ,.. PUMPING LEVEL(below land surface) Well owner's mailing address if-diNeier+t Ehan property owner's address indicated above. . 1 S O n. aner 3 hrs.pumping 7 S g.p.m. , WELL HEAD COMPLETION �� , ,. C7 Pitlessadaptermanufacturer ____,__ Model ____,__________ C7 Casing Protection__,_ ___ _ ❑ 12 in.above grade . . ❑ At-grade(Environmental Welis and Borings ONLY) � '� ' � ` ` �. GROUTING INFORMATION Well grouted? �Yes I� No � HARDNESS OF Grout Material C 1 Nea[cement ❑ Bentonite ❑ Concrete .G�High Solids Bentonite '�� GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from_.�_ _ to_ 3�. _ft. � ❑ yds.,�bags fror�_Q__---toL��_. _ft. LIS� Y��.� bags t� �0�1 b1a�A c.��f t � 2 from__._____ro. ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION CZ�I @�.lOW 90ft 2 '�Q �� eet _ (�t(„L�S l direction ��1V� type Well disinfected upon completion7 �'Yes ❑ No " C I8 tA SOf C ZO PUMP � ❑ Not instalied Date installe��G 7�Lf 1 C18 / ravel I'8 SOft nnanufacturersname _B��L�1_$_�7— _— Motlelnumber__ 6T5�7J _ _ . HP_.� _. Volts �j,II__ - �8�d ?rs Length of drop pipe�_3� _ ft. Capacity _ ._.._. _g.p.m. ep:. Type: '� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ f C�$ CSY�1 rH S Q qBANDONEDWELLS Does property have any not in use and not sealed well(s)? ❑ Yes �No `�an VARIANCE Was a variance granted from the MDH for this well? ❑ Yes �lo TN# WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This weli was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. � ��iadQ.l��tel��ri ��.-�� 72 Licensee Busines ame c.or Reg.No. �._� � �`�� . /. 3-9-01 �nzed Repre hve S�gna we Date Duane Mathe�rs -- �-�7—e� 6 5 5 0 5 3 Name ol Driller Date LOCAL CQPY HE-01205-07(Rev.2/99)