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M/NNESOTA UN/QUE WELL
WELL«OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
County Name WELL AND BORING CONSTRUCTION RECORD `
�enne in
Minnesota Statutes,Chapter 10.3I 8 2 7 8 4 8
Township Name Township No. Range No. Section No. Fraction(sm.--.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED
Orono 11� 23 25 �F NW� SE �� 487 " 11—Ifrl�:
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool ��Driven J Dual Rotary
❑Auger �Rotary � !�Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
l lp� �iW�C�C I�L, C�COT]O 5 �j DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o
t;7i_7 ���V!!1�e
Show exact location of well/boring in section grid ith"X" Sketch map of well/boring location. From ft.To ft.
Showing property lines,
; • roads,buildings,and direction. USE
N � �Domestic [_�',Monitoring [�Heating/Cooling
�� � � � � `�� ,�Y � ❑Noncommunity PWS �� �Environ.Bore Hole [�Industry/Commercial t
��. --'-- --'--- --`-- --'-- '� '
- i .,�+9 [;Community PWS �]Irrigation �Remedial
'`' --'----;--- --`-- ---`-- � Dewatering -
, T � �
, y �� []Elevator (�
� w ' ; ; ; E /\; CASING MATERIAL Drive Shoe? �Yes ��`]Na HOLE DIAM.
� � � \
.. --�-----�-- --F-----:- '.
. '�Steel []Threaded �Welded
'. --�-----�-'-"„-"-;-- ile - -
��M � L]Plastic []
1 _.,�
� � CASING
S � � �, Diameter Weight Specifications
� 4 46Q 1� 7e AS3� R !�6iJ
i 1 Mile� in.To ft. • �lbs./ft. in.To ft.
PROPEFTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To "'" ft.
in.To ft. Ibs./ft. in.To ft. �
Property owner's mailing address if different than well location address indicated above. �p �gp
SCREEN OPEN HOLE
Make ��� Frofl+� ft. To �X'.�� ft.
6I17 �ilu� Crl Dr, Ste 101 Type stain ess stee Diam.
Micmekonka, �''�AT 55343 SIoVGauze�0 Length�Q� y ____
Set between({��'i ft.and it FITTINGS
STATIC WATER LEVEL 1�� ft.�'Below [�Above land surface
t
Measured from � __ � e measured____._ .+ ry hole 'u Yes o �
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
�� ft.after hrs.pumping g.p.m.
- Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
Pitless/adapter manufacturer;,��te���s� Model
❑Casing protection �f 12 in.above grade
❑At-grade r]Well House ❑Hand Pump
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Material��e�Ecocn�__To l.Gt� ft. � C Yds. �]Bags
I I� —�3�� 9�
Matenal From To ft. �Yds. I�Bags
HARDNESS OF Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags 9-
One ba 94 Ibs.cement
or 50 Ibs.bentonite
Cl�j� hr(�{� �� � � NEAREST KNOWN SOURCE OF CONTAMINATION
,: +.-' � Wellis�.$�.._ __ feet � ..___ directionfrom��jt� _ type ;��
�[Sne� �(.,+��^n,J�� jT}iX r� (��7 R'Z Well disinfected upon completion? es ❑No
,,T PUMP
SaTl{�}T Cle�jl �ray ij]Jn �,l�j 1�'rj ❑Not installed Date installed_ ��"�?"`O
+7 Manufacturer's name �iltte2�t� '�
3Atl�y Cl�y �;ray SO�t ?Zf; 370 Model Number HP�voit5
��7 t�G Length of drop pipe 7�n ft. Capacity g.p.m
.�iatriij� C18� ciark br (I��LVfI 3�� �7J Type: Submersible ❑LS.Turbine ❑Reciprocating �Jet [J
�� ABANDONED WEL�S
1 f Yn�� ,�ink r� 423 �`�t3 Does property have any not in use and not sealed well(s)? ❑Yes o
k j VARIANCE
shale Uray/gr tili�d 485 "i`J7 �n/as a variance granted from the MDH for this well? �Yes o 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.
F�on Stodola t�ell Drilli Co. Inc.
Licensee Business Name Lic.or Reg.No.
%
�� �� �.�'�J�d�ZC�
JL
Geitifi�A'�t es ntative Signature Certified Rep.No. Date
' LOCAL COPY !�i*�nes 3�.ier/Anc�r�r I.andcy S� Phi1 �offin�
$2 7 8 4 8 Name of Driller
ID#52603 HE-01205-16(Rev.5/16)
�
- „
Minnesota State Laboratory{D#027-053-119 ' :
TWIl1 Clt�/�/at�P t�1111C le"�b01"BtOf'�/TeSt R@POI't Wisconsin State Laboratory ID#105-10117
: Wisccnsin DNR Lab ID#399073400
_
Client: Don Stodola Well Drilling Report Number: 19-Oooa3 Twin City Water Clinic Inc.
Sample Collection Date: oi/o2/i9 617 13th Avenue South
Address: 3841 North Main Street Sample Collection Time: i5:oo Hopkins, MN 55343
St.Bonifacius,MN 55375 Sample Receipt Date: 01/03/19 Phone: (952)935-3556
Report Issue Date: o�/oa/�9 Fax:(952)935-5077
Laborato Analyte ; Client 1D Parameter Sample Pr�p 5ample Analysis Test .
Sample ID Date 1'im+� Date time Results Units
19-00043 Coliform Drinking Water 01/03/19 13:07 Absent
19-00043 Nitrate/N Drinking Water 01/03/19 13:29 <1.0 R1g�L
19-00043 Arsenic Drinking Water 01/03/19 10:00 O3/04/19 1129 <2.0 µg/L
Lead Drinking Water µg/L
: Well No.: 827848
X No sampies were subtontr�cted;or,the:abovetest res�lt(s)'--Sample pt: We��
with"`•'designati�n w�re produced by a subcontracted
lab,oratary. [tabo7atqry name;arldr�s;;:MDH Lab iD#]: The. Well Adr: 1180 Hunter Drive;Orono;MN
subcontraftedlaboratorymalntainsMDN:Certific�4ionfo�the `;Owner: WooddaleBuilders
��Itl(s)of testing perforrned.
Owner Adr:
Sample Conditions: Sample Temp; 8 °C
Discussion:
Notes . _
I _ .
/�pproved methods us�d in�nalyzirrg the samples,listetEabove;fiave
the following re�tli'ting levels, : iVlaxErtsurtt ca►it�mir��rtt lewel5..
5M9222B-�oliforhi,1 cfu/100 ml Colift��m-c 1.tfp/1tlp ml Nitrate
EPA 3533=Nitrate Nitra�en'expr�5sed as NO3+Nc�2,1,0 rng/L iVitrQger��0.0 mg/L Arseni�,10.(I
..: ...:. _... . �. ... . . . . . ... ..
5NI3�.138'-;Arsenit,.2.(l E�g/I,Le�d;2.0 µg1 L < µg/L ,`.,i. ;Lead,15.0µ6/L
�PA 353,��Nitrit�1�litrogen;l.0 mg/L � Nitrite,l mg/L _ ; .
� ���✓��.
Sample Collected by: X Client _TCWC Approved By: �
Bill Van Arsdale
Laboratory Manager
Tfie results Ifsted in this report,appiy only to the above Iisted sdrl�ples.All routine quality�'ssurante.procpdures were foNowed,unless otherwise :
noted.This analytical report must be reported in�ts entirety.;Alf inethods are certifled tay tite Minnesotd Dep�rtment of Heal�h,unless otherwise '
riot�d.
TCWD Rev 4.0 Page 1 of 1