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Home My WebLink Aboutwell info ' '� MINNESOTA DEPARTMENT OF HEALTH M'N AND BORINI�G NO. ELL WELL C)R BORI�JG LOCATION � ca��Y N,me WELL AND BORING RECORD 7 g 2 016 � �� Minnesota Statutes,Chapter 103I Township Name Township No. Range No:. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Ora� I18 23 29 I+I�iSW SE �� " GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds ,� �- Longitude degrees minutes seconds ❑Cable Tool i,_'i Driven , ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other 3515 Si=th Avoe N Orot�a 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No �+� Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �tVlLLt� From ft.To ft. Showing propert lin , N J �roads, ' 'ngs,and d� c n. USE �Domestic _.Monitoring �]Heating/Cooling ; � , � � "� .. '�- - :: __;___ ___,__ ___;_. �� r�Noncommunity PWS [�Environ.Bore Hole ❑Indushy/Commercial " � ��,_]Community PWS ❑Irrigation ❑Remedial �` --�--- -�-----�-- --�-- ��Elevator ❑Dewatering [] � -�: w ; ; ; ; e T CASING MATEAIAL Drive Shae? ❑Yes o HOLE DIAM. � --;-----�------�--->-- ,. . � �. I ❑Steel ❑Threaded , ,Welded -�� , , , , Mile ��' � Plastic ❑ �- : ------------ --.-----:- 1 � CASING S � Diameter Weight Specifications - �1 Mile� � in.To �7� ft. Ibs./ft. __ �in.Tog�ft � PROPERTY OWNER'S NAME/COMPANY NAME •• " ,' — in.To ft. Ibs./R �in.To�v�_.ft i�t��L� j in.To R. Ibs./ft. in.To ft �`e �t�=� � �� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN�-�4 __ � Make +��1�� _ From _ft To ft. � —1 - _♦ . Type ,�tSlri��$t�l Diam. � :. SIoVGauze ��(3_. . __. Length��I �_�1 '. Set between ft.and it. FITTINGS STATIC WATER LEVEL Measured from 93 _�_ ft.' Below ��, ��,Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) :,� a� ft.after_--- 6 ____..---__._hrs.pumping � g.p.m. ��. ; Well/boring owner's mailing address if ditferent than property owner's address indicated above. WELLHEAD COMPLETION ♦ �;Pitless/adaptermanufacturer�F�te� Model _ ❑Casing protection _ __ �'12 in.above grade c ❑At-grade ❑Well House �Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Matenal[7C[I�I�From Q_To____��tt. __3��Yds. �ags Matenal[�� l/'A� f'kr�ri.___�To�7�ft. U Yds. ❑Bags �� HARDNESS OF Material . ._,,_From To ft. [�Yds. ❑Bags '; GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION � ) � / r^��_� � ,...,�� to�il laek �o s,��C..�� feet �`r direction _C'�'4.�^"f"�' type \ ` Well disinfected upon completion? ,�J.Yes ❑No � CI$ � PUMP ❑Not installed Date installed___ �1��1� e� Manufacturer's name_ �i�€e�___ _ __..__. Model Number_ ___ HP�___Volts �/ r�@� Length of drop pipe�(„S7 ft. Capacity _.__. ____g.p.m ___ 4,� � Type: -' ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ S8[iCl ABANDONED WELLS `�„� � Does property have any not in use and not sealed well(s)? ',^.I Yes o sO�ai F VARIANCE F 1 � r�! Was a variance granfed from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION �1�Q(�j/ 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 ot my knowledge. 7a{ai/ Use a second ded. -. REMAFKS,ELEVATION,SOURCE OF DATA,etc. �' Sa....l�1_ tt�1 S1,.J 1!{�,� t��' ZnGs �II7� ��L�SVlti RC 1 iJf.allias,�-� 4N � Licensee Business Name Lic.or Reg.No. /` ., '" &-2-13 �g C e r sentat e Sign re Certified Rep.No. Date 1 , -- Rob SLod02e LOCAL COPY 7 9 2 0 1 6 - - - ° Name of Driller � IC 140-0020 � HE01205-13(Rev.11/10) . �. Twin City Water Clinic Laboratory Test Report Minnesota State laboratory ID#027-053-119 Wisconsin State Laboratory ID�i 105-10317 Client: Don Stodola Well Drilling Co Report Number: ia-a�os Twin City Water Clinic Inc. Sample Collection Date: 04/i6/13 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: oa/i�/is Phone:(952)935-3556 Report Issue Date: oa/is/ia Fax: (952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 13-4709 Coliform Drinking Water 04/17/13 13:50 Absent 13-4709 Nitrate/N Drinking Water 04/17/13 13:44 <1.0 mg/I 13-4709 Arsenic Drinking Water 04/17/16 830 04/18/13 10:24 2.97 µg/I Lead Drinking Water �L��I Drinking Water Drinking Water Drinking Water Well No.: 792016 X No samples were subcontracted;or the above test result(s) with'*"'designation were produced bya subcontracted Sample pt: laboratory. [Laboratory name;address;MDH Lab ID#].The Well Adr: 3515 Sixth Ave N;Orono,MN subcontracted laboretory maintains MDH Certification for the Owner: Dale Pete�son field(s)of testing performed. Owner Adr. Sample Conditions: Sample Temperature: 9 'C Discussion: Notes: �, Approved methods used in analyzing the samples listed above have the following reporting levels Maximum contaminant levels SM92226-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 rr�l Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic,10.0 µg/I SM3113B-Arsenic,2.0µg/I Lead,15.0µg/I SM3113B-Lead,2.0µg/I , n 1 �,,1��w'�;��.kl�t�_ `�--. j,�,��t Sample Collected by: X Client _TCWC Approved By: ,_ � Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst 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 mustbe reported in its entirety. All methods are certified by the Minnesota Department of Health,unless otherwise noted. TCWD Rev 1.2 Page 1 of 1 , WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � ��O� ' Count}�Narse • WELL AND BORING SEALING RECORD Mnnle9oa�UniqueWellNo. f' Minnesota Statutes,Cha ter 1031 or W-series No. • �7'tP1^t)iil P ��aa�eeia�ea�mk�ow�� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ��.� ?�. '�^ x^' �`j' 3 t�')A ►� "c�nn _ ,,,< .�. �j � GPS Latitude degrees minutes__ seconds Depth Before Sealing ��/ ft. Original Depth ft. LOCATION: � Longitude degrees___ minutes seconds AyIUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location �Single Aquifer ❑Multiaqui(er r, � rT t� r,�,,�r,� W LL/BORING Measured �1 Estimated Date Measured {��'� �� 3515 . i_xt.� AV� • Cn[lO �� : �1 Water-Supply Well �=1 nno��t wen � Show ezact location of well or boring� Sketch map of well or bon i-� ? ' �/ �� in section grid with"X" location,shov{ing prp per ,_Env.Bore Hole [.j Other___ �� R �}below ❑above land surface �I��$,roads,tln�UGdin�s.� N ��_ tj..r CASINGTYPE(S) , _. . -''----'_' -_`-''--'" � ��,Steel [j Plastic L]Tile IJ Other ______ --'--- --�-- ---`-----'"- WELLHEAD COMPLETION �2 � w ; ; ; � ET �� !]Well House .r __,__ __,_____._____r__ Outside: []At Grade Inside: ❑Basement Offset � � ��'h M�ie + ❑Buried ❑Well Pit 1 t �Witless Adapter/Unit ,, ` ❑Buried � ' S ' � ! ❑Well Pit ' �� { �]Other_ n �--1 Mile� � f r]Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) �l r� .� Dia�]e�er ♦ Depth . Set in oversize hole� �AittcuYgY�s�S�Ce-initially grouted? Pro ert owner's mailin address if different than well location address indicated above �/ �� P Y 9 —( in.from U _ to �� R ��Yes �No r]Yes ❑No ❑Unknawn �� _ ��: in.�rom to tt. [j Yes ❑No ❑Yes ❑No , q Unknown +;:�>tac =5 s.,, .. �, ` _ . . . . ...;..g . in.from to ft �1 Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE ' 2r . . ,. y. •._ ., , Well owner's mailing address it diNerent than property owne�'s address indicated above ' SCreen from��__. � [o�� (t. Open Hole from _ t0�"� � ��(�.� _ .. . .,.. .. - � OBSTRUCTIONS j]Rods/Drop Pipe ❑Check Valve(s) [��Debris �;-;Fill ��No Obstruction _ .. .-:n*, .. u � Type o(Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �]Yes [J No Describe FORMATION PUMP . ,�. �. 'i=".- � --_ ., .. If not known,indicate estimated formation log from nearby weli or boring. � -� - � - � • �- ' t • Type ` .. ,: .-..,. / , ��-"� �� '� �� Remaved �Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND�BQRE:,NOt;E r "'-� � No Annular Space Exists [J�Annular Space Grouted with Tremie Pipe i�Casing Perforation/Removal z � _,_____in.from to ___.__ft ❑Perforated ��Removed in.from.----.---_------to ft. - �]��Perlbrated�'."� [ I'Removed Type of Perforator___ ( �Other--------- ------- -- y GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) >' � r i Grouting MaterialJtJ'�!J%CLJ}'1�-L.'T from � to �� ft.__ _ yards�U bags Y from to ft. yards bags from_. to ft. _ yards bags i OTHER WELLS AND BORINGS �+. REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? i_��Yes I�Jo 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 besf of my knowledge. 'km Stac�ola ��ell Drillin�; Co,. inc. 1�91 Licensee Business N`; �� License or Registration No. . , ,;, �/� ---" . � � ..,,,, ,�` �� ,�,, - � ...� C il(edFepresentative Signature s Certified Rep.No. Date ` _ ^ t \ `�. � ��__,.�.,.��-.�,�.�r�,.t-�.. ��.��., H 312 0 0� ---- - - - Name of Person Sealing Well or 8 ing HE-01434-13 IC#140-0423 - Sii2a f