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HomeMy WebLinkAboutWell and Boring Construction Record t. _ . f • MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF (HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD Hennepin Minnesota Statutes,chapter 1031 8 3 9 6 0.6 Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELI/BORING DEPTH(completed) DATE WORK COMP FETED Orono 118 23 33 IF SE SLS 198 i1-29 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger yrRotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location 0 Other 2590 Watertown Rd, Orono 55346 DRILLING LUID WELL HYDROFRACTURED? ❑Yes PrNo Show exact location of well/boring in secti nd wiYq� X:' etch map of well/boring location. bentonite From ft.To ft. t-N Showing property lines, N li roads,buildings,and direction. USE X Domestic ❑Monitoring ❑Heating/Cooling _ [—I ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial ----l---__a_-.-_-1-------__- ❑Elevator ❑Dewatering w�ww..,,,,�ffff❑ w E T CASING MATERIAL Drive Shoe? ❑Yes_$No HOLE DIAM. I ❑Steel ❑Threaded [� elded %Mile SPlastic ❑ B La s+R!ZA CASING T 1 Diameter Weight Specifications 4 —1 Mile--IO in.To 190 ft. lbs./ft. 8 in.To /5y�. �L�A-� cs r— CJS in.To ft. lbs./ft. 6i in.To 20a PROPERTY OWNER'S NAME/COMPANY NAME W Debra elf in.To ft. lbs./ft. Jn.To ft. OPEN HOLE Property owners mailing address if different than well location address indicated above. SCREEN J� Make From ft. To ft. same Type stainless steel Diam. 2" Slot/Gauze .010 Leng4' + 4 Set between .ft.and ft FITTINGS 2NX teader STATIC WATER LEVEL _ — I(� ft.ki Below ❑Above land surface Date measured 11-29-98 Dry hole ❑Yes igNo WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 180ft.after 2 hrs.pumping 30 q.p.m. Well/boring owners mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Whitetrater ,Pitless/adapter manufacturer Model ❑Casing protection 0 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bent terom 0 To 50 ft. 3 ❑Yds. ix Bags Material cuttings From 50 To_IYL ft. ❑Yds. ❑Bags HARDNESS OF Material _ From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION clay brown medium 0 40 /, Ai brown 40 62 Well is feet direction from' }dam type sand/clayD soft © Well disinfected upon completion? 0 Yes ❑No sand/gravel mix medium 62 102 PUMP clay gray medium 102 110 ❑Not installed Date installed 11-30-18 clay/sand gray medium 110 140 Manufacturer's name Schaefer sandy clay gray medium 140 16z Model Number _ f HP •5 Volts 230 brown medium 162 182 ��� reddishModel of drop pipe 147 ft. Capacity g.p.m. sand/gravel mix medium i82 200 Type:'Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes Mi No VARIANCE Was a variance granted from the MDH for this well? ❑Yes yl 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 Go,. Inc. 1691 Licensee Business Name Lic.or Reg.No. i-11-19 7‘,1:1.°Hsentative ,-ur_ Certified Rep.No. Date Rob Stodola LOCAL COPY 8 3 9 6 0 6 Name of Driller ID#52603 HE-01205-17(Rev.5/17) 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: 18-15563 Twin City Water Clinic Inc. Sample Collection Date: 11/29/18 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 15:30 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 11/30/18 Phone: (952)935-3556 Report Issue Date: 12/03/18 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 18-15563 Coliform Drinking Water 11/30/18 11:16 Absent 18-15563 Nitrate/N Drinking Water 11/30/18 11:19 <1.0 mg/L 18-15563 Arsenic Drinking Water 11/30/18 8:40 12/03/18 11:01 3.25 [.tg/L Lead Drinking Water ltg/L Well No.: 839606 X;No samples were subcontracted;or the above test result(s) with'**'designation were produced by subcontracted Sample pt: well laboratory: [Laboratory name;address;MDH Lab ID#]. The Well Adr: 2590 Watertown Road;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Debra Wolf field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 11 °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 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/1,Lead,2.0 pg/L pg/L Lead,15.0 pg/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L Sample Collected by: X Client TCWC Approved By: 6� 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 W MINNESOTA DEPARTMENT OF HEALTH Minnesota a1NeU and Boring H I 362769 WELL OR BODING LOCATION o. WELL AND BORING SEALING RECORDMinneSealing Unique Well No. Bounty Name + Minnesota Statutes,Chapter 1031 oar series No. TownshipHennepk if not knavnt +n Township No. Range No. Section No. Fraction(sm.-4 Ig.) Date Sealed Date Well or Boring Constructed Orono 118 23 33 9E SE SE /243//8 GPS LOCATION-decimal degrees(to four decimal places) i Depth at Time of Sealing 2413 ft. Original Depth ft. Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Locationyf)(Single Aquifer ❑Multiaquifer rf 2590 Watertown Rd, orono 55356 WELL/BORING 'Measured Date Measured S�/l1ITt--# El Estimated VrWater-Supply Well El Env.Well Show exact location of well or boring h map of well or boring ❑T in section grid with"X" loca n,showing property emp.Env.Well ❑Other 7 ft. [ elow ❑above land surface line roads,and buildings.N CASINGTYPE(S) , A --- - --. I I 04 Steel ElPlastic El Tile ❑Other ---;-----;-- --}-- + WELLHEAD COMPLETION W E� Outside:XPitless Adapter/Unit El At Grade Inside: ❑Basement Offset 'h Mile ❑Well Pit ❑Buried ❑Well House --t--;-'I.--------- 1 ❑Well Pit El Other ❑Buried 1--1 Mile--1�� El Other For multiple temporary environme,p ovi a-a oe CASING(S) information,a site sketch,and geology on a separate page. Diameter' , Depth e Set in oversize hole? Annular space initially grouted? PROPERTY OWNNEER SS NAME/COMPANY NAME _6,_._.in.from a to 2...5q ft. El Yes ElYes No ❑YesNo El Unknown Pros mallfig dress it different than well location address indicated above in.from to ft. ❑Yes El No El Yes ❑No El Unknown in.from to ft. ❑Yes El No El Yes ❑No ❑Unknown SCREEN/OPEN HOLE r • Screen from 2'x`3 to 26 3 ft. Open Hole from to ft. WELL OWNER'S NAME/COMPANY NAME OBSTRUCTIONS Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe El Check Valve(s) ❑Debris ❑Fill Aflo Obstruction Type of Obstructions(Describe) Obstructions removed? El Yes El No Describe PUMP HARDNESS OR GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Not Present ElPresent,Removed Prior to Sealing ❑Other If not nown,indicate estimated formation log from nearby well or boring. Type 0 6243 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE 4116— cv KNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing Perforation/Removal teasing Diameter in.from to ft. El Perforated ❑Removed in.from to ft. El Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑YesNo TN# - GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) �,L r r Grouting Material#41602, '/I�IV/ from_to 240.3 ft. yards y/ bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? El Yes XNo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 Drilling Co,. Inc. 1691 Licensee Business Name License or Registration No. i ted pres ti a lure Certified Rep.No. Date 362769f` c �� 1 LOCAL COPY H Name of Person Sealing Well or Bor HE-01434-16 ID#53159 9/178