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Home My WebLink Aboutwell info rt.:. ,� , ,__ . .., , _ ._ _ . . _. _ . . ....,.,:_ , _ � MINNESOTA UN/QUE WELL � OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. co� -,e WELL AND BORING CONSTRUCTION RECORD 81 H O O� �7�.��t�c�` Minnesota Siatutes,Chapter 103I ?rwnship Name Township No. Range No. Section No. Fraction WELL/BORWG DEPTH(completed) DATE WORK COMPLETED �- ,, I RO n 11-24-15 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD % Latitude Longitude ❑Cable Tool [�Driven � ❑Auger �Rotary � House Number,Street Name,City,and ZIP Code of Well Location ❑Other - DRILLING FLUID WELL HYDROFRACTURED? ❑Yes a Show exact location of well/ oring in section grid with"X:' Sketch map of welUbori loc ion. �tet' From ft.To ft. Showing pro erry;�nes, — N _ roads,buildings,an c�t[�Ltion. USE �Domestic ❑Monitoring ��Heating/Cooling = � � � � ) Noncommunity PWS ❑Environ.Bore Hole '^'�Industry/Commercial --�-----J------�-- ---•-- � h�� -�} ° +, � , , � ,� '''� ❑Community PWS ❑Irrigation [�Remedial 4 : _.�--- --�-----�-----:— ❑Elevator j]Dewatering [� ;.. w ' ; ; ; e T CASWG MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. ' ' ` ` I _S ❑Steel ❑Threaded ❑W Id d e e � ; ; ; ; nn�ie r� y v,� > Plastic --:--. , , , 1 � 7 ---;---s--:-- ---:- �. � � � � CASING � � � � Diameter Weight Specifications �-1 Mile� � ? � � in.To 1..�_ft. Ibs./ft. _ �in.To_�ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. V'�__in.Ta1Hd ft. � in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make �� From ft. To ft. Type g�8;2[��$ ,,,�� Diam. - SIoUGauze �� Length��, �t Set between ft.and fl. FITTINGS STATIC WATER L V L Measured from 77 ft. Below ❑Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ' �65 ft.aRer g 2 hrs.pumping �0 4 p m_ Well/boring owner's mailing address if different[han properry owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer�t��t�r Model �Casing protection �12 in.above grade ❑At-grade ��Weli House (�Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material t�n.'��P From_�__To�_ft. � __�__ ❑Yds. �Bags �� ; Material�tu�_��__��To__�,��_ft. �Yds. �Bags HAFDNESS OF Matenal From To ft. ❑Yds. i�Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION $$(j� ��,j __feet CJ✓ direction -_ a. -� �--� _type Well disinfected upon completion? �Yes ❑No PUMP ❑Not installed Date installed _ �1"2 J�i J �.'I8 it Manufacturer's name Madel Number _ HP��_Volts�'� sar� Length of drop pipe Z26 _ft. Capacity g.p.m r.� Type�Submersible �'_,LS.Turbine [;Reciprocating ❑Jet ❑ S�IlU C H a ABANDONED WELLS �_3 Does property have any not in use and not sealed well(s)? �]Yes � �No �K-� = VARIANCE �y� Was a variance granted from the MDH for this well? ❑Yes No TN# FA1 `� 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. t-r�$V Use a sec et,il needed. EMARKS,ELEVATION,SOURCE OF DATA,etc. Ibn Stoc�ola �11 t)rf llin� co,. Inc. I691 Licensee Business Na e Lic.or Reg.No. ..`�� , � .-�� 12-17-15 ; ;^'�,' "s�`` ' - — � erti�fgd`R rese r e Si�r(ature Certified Rep.No. Date � _ LOCAL COPY 818 0 0 3 Name of Driller �b S��p�� ID#52603 HE01205-15(Rev.8/13) s � ' Minnesota State Laboratory lp#027-053-119 � TWI11'Clty�at8r C�1111C'�abOPat01"�/TESt Re�701't wisconsin state laboratory ID#105-10117 Wisconsirr DNR lab ID#399073400 CIle11t: Don Stodola Well Drilling Report Number: 15-13892 TWI11 Clty Wetel'CI1111C It1C. Sample Collection Date: 11/30/15 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: �:00 Hopkins,MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: ii/30/15 PhOne:(952)935-3556 Report Issue Date: �z/o1/�5 Fax: (952)935-5077 Laborata Analyte Client ID Parameter -Sample Prep Sample Analysis Test Sample ID Date ' Time Date Time Results Units 15-13892 Coliform Drinking Water il/30/15 1420 Absent 15-13892 Nitrate/N Drinking Water 11/30/15 14:30 <1.0 mg/L 15-13892 Arsenic Drinking Water 11/30/15 9:30 12/01/15 13:47 <2.0 µg/L Lead Drinking Water µg�� Nitrite/N Drinking Water mg�L Drinking Water Drinking Water ' Well No.: 818003 X No samples were subcontracted;or the above test resuk(s) ' Sample pt: Well with'*•'designation were produced by a subcontracted laboratory. [Laborato�y name;address;MDH Lab 1D#]. The Well Adr: 75 Stubbs Bay Road N;Orono,MN subco�tracted lahoratory rnaintains MDH Certification for the Owner: Bruce Malby field(s)of testing performed. ` ' Owner Adr: Sample Conditions: Sample Temp: 14°C Discussion: Notes: Approved methods used in analyzing the sampleslisted Maximum contaminant levels: above heve the following reporEing levels:' Coliform-�1 cfu/100 ml ' SM92228-Coliform,l cfu/100m1 Nitrate Nitrogen 10.0 mg/IL SM4500F or EPA 3532-Nitrate Nitrogen,l.0 mg/L Arsenic,l0A µg/L � SM31136-Arsenic,2Aµg/I,Lead,2.0 µg/L Lead,15.0µg/L , EPA 353'.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L r �� Sample Collected by: X Client _TCWC Approved By: ' �`��'vf� `"��`�� Bill Van Arsdale Alan Senechal Laboretory Manager Senior Analyst The results listed in this report apply only tq the above listed samples,AO routine quality assurance procedures were followed,Unless otherwise noted.This a�alytical report must be reported in its entirety.All methods,are certified by the Minnesota Department of Health,unless otherwise � noted. TCWD Rev 2.0 - '` Page 1 of 1 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealmg No. ell and Boring �„' °"� � � :J � Q County Na� WELL AND BORING SEALING RECORD Minnesota Unique Well No. J o or W-series No. Minnesota Statutes, Chapter 7031 Lu8veb1��k„�o�k�w�, SGj /(,�/ To ship N e Township No. Range No. Section Na Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted � � - �. .� �� GPS LOCATION- decimal degrees(to four decimal places) i . Depth Betore Sealing_1�� it Original Depth_._.___ . ft. Latitude_.__ _ _ Longitude __________ - --- A UIFER(S) STATIC WATER LEVEL � Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ;_�Multiaquifer � , ,�r WEWBORING i Measured ', �.Estimated Date Measure �_ e �� r� �5� ;Water-Su I Well � � / pp y ��MoniL Well Show exact location of well or boring Sketch map of well or or��qqqggg �( ,- in section grid with"X:' location,showing prop rt� �.�Env.Bore Hole [j Other __��_ _ ft. /ry below �L!above land surface N lines,roads,and buildi g CASING TYPE(S) __'___ __i___ ___`__ ___�__ M.. ,�� .Steel f �Plastic ��_�Tile !_i Other______ � --''-'--�--- --+-- ---`-- WELLHEAD COMPLETION � , W ; ; ; � ET _ , � � � � � 'h nniie -�Buried _�Basement Ofiset ' _ _____ ___ __ __ _ _ Outside: . i Well House �_,At Grade Inside: ' .� ; ; f ' dless A p dUnit -� �._, ell Pit �, �P� da te � �W 1 _ ; �Buried ' ' ' S � i_j Well Pit s .¢' _ �_i Other i 1 Mile--� :� �� .�_1 Other — --�------- � PROPERTY OWNER'S NAME!COMPANY NAME CASING(S) A; Dia �� Depth � Set in oversize hole? Annular space initially grouted? Property ownei's mailing�a dress if different than well location address indicated above .� in.fromQ t ft. I_�Yes '�l'.No �_I Yes �No ,_�,Unknown ��— �o� _ __ln.from to_ ft. !]Yes �'�No _;Yes ,_;No i_j Unknown in.from_ ro_.____ft. �Yes ❑No .�Yes �_�No j_l,Unknown WELL OWNERS NAME/COMPANY NAME SCREEWOPEN HOLE , ! Well owner's mailing address if different than property owner's address indicated above SCreen from_�� . _to_S�___it. Open Hole from__._______ to_______ft. � OBSTRUCTIONS �RodslDrop Pipe '-]Check Valve(s) �I Debris ��,_i Flll �No Obstruction Type of Obstructions(Describe)__ .__._ ____ __ _ ___ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obshuctions removed? '�.]Yes I )No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. , Ls` e •`..J JSg TYPe___—_ ----- --_-- ------ f_I Removed �Not Present ��,J Other___ __. _ __ _ __ _ _ __ _ _ �t METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: ��No Annular Space Exists �_'Annular Space Grouted with Tremie Pipe �,.;Casing Perforation/Removal ; _______in.from to ft �j Perforated i I Removed '�, `� __in.from to ft. i_J Perforated �Removed �� — ___._�_.------ ------- -- Type of Perforator _ ; VARIANCE Was a variance granted irom the MDH for this well? ,�.'.Yes �,No TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � r'` `y �7 � : �. ; Grouting Materiati+'��i��,�/�_ from_.Q _ 1��`j�,__ ft. yards_jl _ __ bags �� ._._ from to______ ft.____ yards_ __ bags _ _ ___ from_____ to ft.__.___,___ yards ___ bags � OTHER WELLS AND BORINGS 'i� REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ��_ ''Yes .No 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 best of my knowledge. tk�n Sto�ola �1e11 [�cil lin� Co,.Inc. 16�1 ---- - �-— —- ---- ---- __-------- -------_ g-----— Licensee Business ame License or Re istration No. ; % ,.� . ,� :�'�'` � �� /� .30 . �s �� , f :� - -_ _ - --------___ _ -- � e�r '�d�REfp�'esentatroe Sgn '}e Certified Rep.Nn. Date 4 �,,." l,; ,, LOCAL COPY ---- = �i._- ='-'- _ _ --- " 3 3 5 �9 8 Name ol Person Sealing Well or Bor� � ,�- _ � � HE-01434-14 IC#140-0423 � , 5�i3R