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Home My WebLink Aboutwell info f� MINNESOTA UN/QUE WELL WELL OR'30RtNG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Gfwnty Name WELL AND BORING CONSTRUCTION RECORD g 18 012 Minnesota Statutes,Chapter f03I Town ip Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED 1�r0!10 7'1 T ' '�'3'�°' OE3 t+� 1SlW�/SW �/ 13h n ��S�l.�i GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven �Auger �d'Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other j ` 4�YS SC. Ancl�ew� SC. OCOCIO 55364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in sectioR,grid with"X:' Sketch map of well/boring location.� �� j�ter From ft.To (t. Showing property lines, — — � (� roads,buildings,and direction. USE � " Monitorin Heatin /Coolin � N , Domestic L� 9 ❑ 9 9 � ; , , , , i — _ __;___ __�_ _�__ ___;_ � Noncommunity PWS ❑Environ.Bore Hole U Industry/Commercial s f !]Community PWS ��Irrigation ❑Remedial --'- �-- --` `_ + � .,�/,,..,�•;,� �„ ❑Elevator �]Dewatering ❑ ' W ' ' E y� `�'� CASING MATERIAL Drive Shoe? ❑Yes�No HOLE DIAM. � ❑Steel ❑Threaded ❑ elded - '' _ ' ��Mile' ] �� ; ; �. � Plastic --�--- --�-----�-- -�— �I CASING , S `; �f Diameter Weight Specifications �_�M�_� � 1 + _�_in.To i�R ft. Ibs./ft. �_in.To��fl. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJft. �in.To��ft. in.To ft. Ibs./ft. in.To ft. Swanson �(k�w�3 OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 13h� t��me1 �� Make Jahn� From ft. To ft. a`.�j CC )�/� TyPe��$ii^te$v��c�Diam. 7� A•sC�.li[l8� ��1 J J3�i�7 SIoUGauze � Length •s_ Set between ft.and ft. FITTINGS STATIC WATE L ' � Measured from �R ft. Below [J Above land surface Date measured � � WELL OWNER'S NAME/COMPANY NAME pUMPWG LEVEL(bel w 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 [f Pitless/adapter manufacturer Model - ❑Casing protection ❑12 in.above grade [J At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cemeM,concrete,cuttings,or other) Matenal��i'tE From � To �u n. 3❑Yds. [�'Bags Material YISC�� 5(� To I2$ h. �vds. ❑sa95 HARDNESS OF Material From To ft. [',Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION sand cla �n}WTZ ��1�11 V Z� 1 ' '� feet a..i direction __��tYPe Well disinfected upon completion? Yes ❑No CiS' '`CA {tfediL�i{ �(1 7 PUMP _p L [�Not installed Date installed �R�_�` C�.t3 St"�t2C� �'C8 1!teCj�lNf1 ��7 ��? Manufacturer's name ,��] r- Model Number HP !.5 Volts $c'3itC1 RI�.X SO£t �� 2`� Len thofdro i e 1f°S ft. Ca acit m 9 PPP P Y 9P _ �tQC�r, �� nl �� Type: �Submersible ❑LS.Turbine [��Reciprocating []Jet ❑ ZA! G�f ABA DONED WELLS �LKi C la�' rE�� i�j 136 137 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 r 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 sheeG if needed. REMARKS,ELEVATION,SOURCE OF�Tg�eCEIVED E D4n Stociola Well Drillin� Co . Inc. 16�?1 Licensee Business Name Lic.or Reg.No. JUM � .� 7�, � '',,�' � , ,. �F ,!';�,� ' _ ;-��'�,,�-� 2-25-16 ✓ f"F'"'- .f -�I�Oc ��9ep�esentatroe Sgnatur � Cer4fied Rep.No. Date �- ORONO Rob Stcx�ola LOCAL COPY 818 012 Name of Driller ? ID#52603 HE-01205-15(Rev.B/13) Minnesota State Laboratory ID#027-053-119 Twin City Water Clinic Laboratory Test Report w�5�o�s��scace�boracory�on�05-�0�� Wisconsin DNR Lab ID#399073400 Clietlt: Don Stodola Well Drilling Report Number: 16-01314 Twin City Water Clinic Inc. Sample Collection Date: 02/08/16 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 7:0o Hopkins, MN 55343 St.eonifacius,MN 55375 Sample Receipt Date: o2/os/16 Phone:(952)935-3556 Report Issue Date: 02/09/16 Fax: (952)935-5077 Laborator Analyte Client ID Parameter, Sample Prep Sample Analysis_ Test Sample ID Date Time Date Time Results Units 16-01314 Coliform Drinking Water 02/08/16 11:46 Absent 16-01314 Nitrate/N Drinking Water 02/08/16 12:14 <1.0 mg/L 16-01314 Arsenic Drinking Water 02/08/16 8:00 02/09/16 15:41 2.24 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water Well No.: 818012 X No samples were subcontrected;or the above test result(s) Sam le t with""designation were produced by a subcontrected p P � Well laboratory. [Laboratory name;address;MDH Lab ID#]. The Well Adr: 4645 St Andrews St;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 9°C Discussion: Notes: Approved methods used in analyzing the samplesJisted Maximum contaminant levels above have the following reporting levels: Coliform-<1 cfu/100 ml SM9222B-Coliform,1 cfu/100 ml Nitrete Nitrogen 10A mg/IL SM4500F or EPA353.2-Nitrate Nitrogen,l.0 mg/L Arsenic,10.0 µg/L SM3113B-Arsenic,2.0µg/I,Lead,2.0 µg/L Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L : . ' ,,1.�� .,A% L9:.�+'.rrr,t..��X...f'c.qC�{� Sample Collected by: X Client _TCWC Approved By: ; �:�t�r 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 must be reported in its entirery.All methods are certifiedby the Minnesota Department of Health,unless otherwlse noted. TCWD Rev 2.0 Page 1 of 1