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Home My WebLink AboutWell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H `� � �� County Name WELL AND BORING SEALING RECORD M nnleso a�Unique Well No. �l " Minnesota Statutes,Chapter 103! or W-series No. (Leave blank�il no�known) T TtlW Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed v. ,i v. G ION- decimal egrees(to fo`ur decimal p aces) " � Latitude Longitude_ Depth at Time of Sealing �f� ft. Original Depth ft. AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �,,/ ", WELL/BORWG Measured Date Measured��)f1r1� �!_ ❑Estimated 17bC� �oreline >�r, ?�(af'IO 553�1 Water-Su I Well pp y ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring 7 in section gnd with"X:' location,showing property Ern.Bore Hole ❑Other ��_ft. �below ❑above land surface lines,roads,and buildings. :; N �.,•--..._ , CASING TYPE(S) . r� . : � � � � � . --'--- -i-- --`- --'- ..;... �%� Steel ❑Plastic ❑Tile ❑Other '� --'--- --'--- ---�-----`- 3 �= „��T� WELLHEAD COMPLETION - �, W I I I I E i [ � I I I IO ::.,� ��c�rv�� __;____;_____�_____;__ T i �a�� Outside:�Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset '�M� �fS�y ❑Well Pi[ ❑Buried ❑Well House /� �J ❑Well Pit �� 7 �v�/ S ❑Other _ ❑Buried ^. �1 Mile n ❑Other Ci�N�F�RQN�_ �� ._ . .__,... .. �.�,. , PROPEFTY OWNER'S NAME/COMPANY NAME CASING(S) Diam t�r � Depth � Set in oversize hole? Annular space initially grouted? W` o �ilin !if diNerent ihan well location address indicated above � �in.from 0 to f/2 ft. ❑Yes �No ❑Yes ❑No ❑Unknawn �� 7�..V }�+,,�t L$Rc �J't� ��13 in.from to ft. ❑Yes C]No ❑Yes ❑No ❑Unknown ` tdayzata, ��I 5539I , � in.from to ft. ❑Yes ❑No ❑Yes �:�j No ❑Unknown � WELL OWNER'S NAME/COMPANY NAME SCHEEN/OPEN HOLE / ♦ i ? Well owner's mailing address it ditterent than property owner's address indicated above Scfeen from //2. to�L�ft. Open Hole(rom t0 ft. i OBSTRUCTIONS � �i _; ❑Rods/Drop Pipe ❑Check Valve(s) ��Debris ❑Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP � If not known,indicate estimated formation log from nearby well or boring. . Not Present ❑Present,Removed Prior b Sealing ❑Other � _.. � i� Type ��! METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE �o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal sing Diameter . in.from ,_to fL [�Perforated ❑Removed +� in.from to ft. �-J Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# GROUTING MATERIAL(S) (One bag oi cement= 4 Ibs.,one bag of bentonite-50 Ibs.) i / � GroutingMaterial/(�F_ IQT�'L/n��/ from U to f/C.0 ft. yards�Q bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? [�Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. ?x�n "toclola t�ell �rillin�; Co,. Inc. I692 Licensee Business Name License or Registration No. . ,, _,!_.. �, - :�-'''�f� �. �-:; � 7 _ ��- Cpriified Reprc�sent�Signattir�� Certified Rep.No. Date � n -�-�- LOCAL COPY H � � �-•� -�- � - ' �,, _�z.,�-, .� � ��2 6 7 Name ol Person Sealing Well or Boring � HE-01434-15 ID#53159 an6R MINNESOTA UNIQUE WELL OR�'►�RING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD g 2 6 6 61 Necmepin Minnesota Statutes,Chapfer 1Q3I Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED _ �C'ex�0 117 � 23 1Q I�W SE I�IE r � �� 33Q "� 1 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool [I Driven ��Dual Rotary ^ L]Auger �Rotary [.�Rotasonic - House Number,Street Name,City,and ZIP Code of Well Location ❑Other I76fl Shoreline �r� �rQYId DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �ent{��Ce From ft.To ft. c � � roperty lin , � , roads,buildings, d direcf USE ; N � Domestic ❑Monitoring ❑Heating/Cooling _ ,__ ._,___ �_ __;_ ❑Noncommunity PWS �Environ.Bore Hole ❑Industry/Commercial ' �]Community PWS ❑Irrigation j]Remedial -- - -- � �]Elevator ❑Dewatering ❑ ". '�'� ' ; ; E T CASING MATEAIAL Drive Shoe? �Yes ❑No HOLE DIAM. - - �--- -�-----�— '- �-- I : - �Steel �Threaded n Welded s. ; , , , /z Mile , , , , II ❑Plastic �] - '-----,----�- ---�- 1 � CASING S � Diam/�eter Weight Speci(ications �--i M;ie—� `'� in.To ��ft. Ibs./ft. � in.To �� ,>:�r_,�,�.Q,;�,....�e.. �.�. . ► 37 f� 3 �. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. iK.To �. .. �+Lr��(m� I�.+• in.To ft. Ibs./tt. in.To ft. Property owner's mailing address if different than well location address indicated above. p SCREEN OPEN HOLE 7iN'1 c`�st i.KLke w7''�� /►.213 Make From �O� fl. To �� ft. . �� Z$t8� ��t 553912 Type Diam. ; SIoUGauze Length s Set between_ ft.and ft. FITTINGS ' STATIC WATER LE1VEL1 f Below �-�Above land surface Measured from_�1-l�asured _Dry hole ❑ Yes No WELL OWNER'S NAME/COMPANY NAME pUMPING LEVEL(below land surface)L �� ft.after v hrs.pumping � _g.p.m. '. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t7L.=��$�er i Pitless/adapter manufacturer Y¢111 ,_ Model °� i ❑Casing protection__ �12 in.above grade ❑Abgrade ❑Well House [J Hand Pump � GROUT W FORMATION(specify benronite,cement-sand,neat-cement,concrete,cuttings,or other) Material�t�ite From v To 2$5 n. 18 �Yds. �Bags Matenal From To ft. �Yda ��Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Matenal From To ft. ❑Yds. ��Bags MATERIAL Driven casing seal From GDD To zss _Bags �ne bag=94 Ibs.cement or 50 Ibs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION clay/sarid brotm meditan 0 19 � ^� -- �' -- Well is_. .1_ l.�---._ __feet . _ �_ _ ___direction from�� -� type — �---- Well disinfected upon completion? �Yes ❑No cl�y/sarxl gray med.i�an I9 131 PUMP s�ridy clay/�rave ced medi�n 131 260 °"°"�S`a°ed Date installed �� Manufacturer's name sLHIl� ('�(� y�rd �� fLo Model Number HP 1.5 Volts L Sri G174? L Length of drop pipe 12`j ft. Capacity g.p.m g�1$1e�9��E�T1� �it� �f� 2`Jil 2p5 Type: Submersible ❑LS.Turbine ❑Reciprocating f�Jet I� ABANDONED WELLS L�e} shalelsandstone ��te 1 e2ird 2�� 3� Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION This well 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. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. ��C�IVED T�on Stcx3ola �Tell I�rillin�g Co, znc. 1�91 Licensee Business Name Lic.or Reg.No. APR ± � 201� .� '�" 1-17-18 CITY OF ORONO C ifiecl Representative Signature Certified Rep.No Date k ; R.(3h StOC1018 LOCAL COPY 8 2 6 6 61 Name of Driller � ID ri52603 HE-01205-16(Rev.5/16) _ a . Minnesota State Laboratory ID#027-053-119 TWII1 CI��I ws'�ter C�It11C La�J01'8t01'�/TeSt R@p01"t wisconsin state I.aboratory ID#105-20117 Wisconsin DNR Lab ID#399073400 Client' Don Stodola Well Drilling Report Number: 17-14052 TWI�City Wdt21'CI1111C I�C. Sample Collection Date: 11/16/17 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 15:30 Hopkins, MN 55343 st.sonifacius,MN 55375 Sample Receipt Date: 11/17/17 Phone:(952)935-3556 Report Issue Date: 1�/zo/�7 Fax: (952)935-5077 Labarato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 17-14052 Coliform Drinking Water il/17/17 12:40 Absent 17-14052 Nitrate/N Drinking Water 11/17/17 12:00 <1.0 mg/L 17-14052 Arsenic Drinking Water 11/17/17 9:00 il/20/17 11:40 5.23 µg/L Lead Drinking Water µg/L mg/L . weU No.: $26661 X No samples were subcontraded;or the above test resulf(s) with'**'designetion were produced by a subcont�acted Sample pt: well laboratory. [Laboratory name;address;MDH Lab IDqj. The Well Adr. 1760 Shoreline Drive;Orono,MN subcontracted laboratory maintains MDH Certificationfor.the; Owner. Nor-Son Inc. field(s)of#esting performed. Owner Adr: Sample Conditions: Sample Temp: 12°C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels SM9222B-Colifo�m,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate EPA 353.2-Nitratie Nitrogen expres�ed as NO3+rv02,1.0 mg/L Nitrogen 10.0 mg/L Arsenic,I0.0 ` SM31136-Arsenic,2.0µg/I,Lead,2.0 µg/L µg/L Lead,15.0µg/L EPA 3531-Nitrite Nitrogen,1.0 mg/L Nitrite,l mg/L Sample Collected by: X Client _TCWC Approved By: �A=��^€�'`� Bill Van Arsdale Laboratory Manager The results listed in this report apply only to the:above listed samptes:All routine quality aswrence procedures were followed,unless oth�rwise noted.This analyticai report must be reported in its enYirety.Ail methods are certified by the Minnesota Department of Health,unless otherwise noted. TCWD Rev 4.0 Page 1 of 1