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Home My WebLink AboutWell and Boring, Sealing Constsruction Record TA UNIQ WELL 019 BORING'LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN ES AND BORING NO.WELL County Name WELL AND BORING CONSTRUCTION RECORD 8 2 6 6 5 3 Hennep Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.–.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 09 SE NWy,SW V. 290 n. 12-21-17 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude . ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger ig Rotary i ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other -` 3017 Nori-k Shore Dr, orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes,gNo Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. bentonite From ft.To ft. Showing property lines, N 4 Koads,builipack and direction. USE 24 Domestic ❑Monitoring ❑Heating/Cooling JJ1-1-1 1 --`rte Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial , Community PWS ❑Irrigation ❑Remedial ---4---.4-----;______;--- ,. ❑Elevator Dewatering w E T CASING MATERIAL Drive Shoe? y—lZYes ❑N o HOLE DIAM. -t-- -;- 1-- --F- I Steel Threaded' ❑Welded kMile ❑Plastic 0 : 1 t ..NN, CASING 3 wn \\ Diameter Weight Specifications 1-----1 Mile -41----0-1-0 245 ft. lbs./ft. in.To_ t. i PROPERTY OWNER'S NAME/COMPANY NAMEin.To ft. lbs./ft. lTo 726.Swanson Homes n.To ft. lbs./OPEN HOLE ft. /en.�To�90t. Property owner's mailing address if different than well location address indicated above. SCREEN 1360 Hamel Rd Make From '245 ft. To '99fl ft. 136, 1 g Type Diam. Medina, MN 55340 Slot/Gauze Length Set between ft.and ft. FITTINGS STATIC WATER LEVEL 35 ft.❑Below,,Above land surface Measured frontOp of gel-tate measured 12-21-17 Dry hole ❑Yes/ No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 165 ft.after 5 hrs.pumping 50 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Whitewater Pitless/adapter manufacturer Model ❑Casing protection 2 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material benton Brom 0 To 5pft. 3 ❑Yds.SI Bags Material From To ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One ba 94 lbs.cement Driven casing seal From 231 To 245 Bags g or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION ([ topsoil black soft 0 4 Well is 2ail feet 4/ direction from n' i ; 4-3 • t .- 'r type.� Well disinfected upon completion? xYes ❑No /�t_�_, C.$3,k e� clay/sand gray soft 4 36 PUMP r ❑Not installed Date installed 9-8-18 .1 • . '.• • Manufacturer's name Schaefer �n Model Number HP1.5 Volts 230 sand/clay gray um 162 226 Length of drop pipe 63 ft. Capacity g.p.m shale/sandstone yellow snft 226 245 Type:DC Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ y ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes 'No sandstone/shale white/ mw'dtum/ / VARIANCE hard' rd 245 290 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. Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. 9-27-18 --er,'_. eprese &( �nature Certified Rep.No. Date LOCAL COPY 8 2 6 6 5 3 Name of Driller w ' .. ID#52603 FIE-01205-1601.m5/16) Minnesota State Laboratory ID#027-053-119 Twin City Water Clinic Laboratory Test Report Wisconsin State Laboratory ID#105-10117 Wisconsin DNR Lab ID#399073400 Client: Don Stodola Well Drilling Report Number: 17-15527 Twin City Water Clinic Inc. Sample Collection Date: 12/25/17 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 14:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 12/26/17 Phone: (952)935-3556 Report Issue Date: 12/27/17 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 17-15527 Coliform Drinking Water 12/26/17 12:46 Absent 17-15527 Nitrate/N Drinking Water 12/26/17 12:49 <1.0 mg/L 17-15527 Arsenic Drinking Water 12/26/17 9:00 12/27/17 12:04 6.94 pg/L Lead Drinking Water pg/L mg/L Well No.: 826653 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: well laboratory. [Laboratory name;address;MDH Lab ID#]. The Well Adr: 3017 North Shore Drive;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Swanson Homes field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 15 °C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: SM9222B-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate EPA 353.2-Nitrate Nitrogen expressed as No3+NO2,1.0 mg/L Nitrogen 10.0 mg/L Arsenic,10.0 SM3113B-Arsenic,2.0 pg'/I,Lead,2.0 µg/L 1.1g/L Lead,15.014/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L Sample Collected by: X Client _TCWC Approved By: Bill Van Arsdale Laboratory Manager The results listed in this report apply only to the above listed samples.All routine quality assurance procedures were followed,unless otherwise noted.This analytical report must be reported in its entirety.All methods are certified by the Minnesota Department of Health,unless otherwise noted. TCWD Rev 4.0 Page 1 of 1 Q - MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H RECORD 3 4 4 2 5 J" WELL OR BORING LOCATION Sealing No. County Name WELL AND BORING SEALING Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or w seif not ries No. -LL Hennepin Well or Boring Constructed Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed ..,- Orono I 117 I 23 09 S#' NV SFT 2.(0 J i9N-' 17 GPS LOCATION-decimal degrees(to four decimal places) � r ft. Depth Before Sealing 2_-,e ft. Original Depth Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer WELL/BORING ( Measured ❑Estimated Date Measured.5nmF 3017 North Shore Dr, Orono Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring ❑Env.Bore Hole ❑Other .3 ft. below ❑above land surface in section grid with"X" location,showing pro 1//J lines roa and bw9^ CASING TYPE(S) N Ai z. o i Steel 0 Plastic ❑Tile ❑Other WELLHEAD COMPLETION ` w E T Outside: ❑Well House ❑At Grade Inside: LI Basement Offset h Mile �Pitless Adapter/Unit ❑Buried ❑Well Pit -Li T 7 ❑Buried j I Well Pit III Other S F---1 Mile---') ❑Other PROPERTY OWNERS NAME/COMPANY NAME CASING(S) Swanson Hf?f1tPR Diameter,i / Depth/,, / Set in oversize hole? Annular space initially grouted? Property(ownerZ(Q s mailing address if different than well location address indicated above ea in.from tn to / ft. ❑Yes to ❑Yes ❑No ❑Unknown 1360 Hamel Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Medina, MN 55340 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r Well owners mailing address if different than property owners address indicated above Screen from to ft. Open Hole from Awl to 2 7 Q ft. OBSTRUCTIONS e 'Rods/Drop Pipe ❑Check Valve(s) ❑Debrisn ❑Fillll ❑No Obstruction Type of Obstructions(Descr.ibbeL/ft//(i0� /L/_r 4 / UCOP HARDNESS OR FROM I TO Obstructions removed? *es ❑No Describe GEOLOGICAL MATERIAL I COLOR I FORNATION '1 PUMP If not nown,indicate estimated formation log from nearby well or boring. ��A /� _n, Type (�tJ it...>_/ OOslo f wRemoved ❑Not Present ❑Other 4/ ; 7X METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) Grouting Material//e,47 f I'Ain A.)7 from Q to 777 ft. yards_2.E 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 K'Jo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 7� 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. don Stodola Well frillin ; Co,. Inc. 1691 Licensee Business Name License or Registration No. / ~ //—/ � / C ifi: 'e,!s- ha Signa l Certified Rep' 10. Date i LOCAL COPY H 3 4 4 2 5 Name of Person Sealing Well or Boring j 5/135 HE-01434-14 ID#53159 L/