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HomeMy WebLinkAboutWell and Boring Construction Record 2-17-19 ' MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. , County Name WELL AND BORING CONSTRUCTION RECORD Pepin Minnesota Statutes,chapter 1031 8 3 9 617 Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 ,,,NE Nis sq 147 n. 2-17-19 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger • ,'Rotary ❑Rotasonic House,usNumber,Street Name,City,and ZIP Code of WellLocation ❑Other 480 Park Ave, ©sono 5356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes 'No :'Show exact location of well/boring in section grid with" Sk-'•ch map of well/boring location. bentonite ,l - From • ft.To ft. owing property lines, N ads,b ildings,and direction. USE Domestic ❑Monitoring ; ❑Heating/Cooling ; � ❑Noncommunity PWS Li Environ.Bore Hole ❑Industry/Commercial { ❑Community PWS ❑Irrigation ❑Remedial '__-__- ❑Elevator ❑Dewatering ❑ w l E r CASING MATERIAL Drive Shoe? ❑Yes Q No HOLE DIAM. ❑Steel ❑Threaded ❑Welded '/z Mile ...,:l) PIBStiC ❑ r . 1CASING s Diameter 9 Weight Specifications ) 1 Mile_____IS 4 in.To 137 ft. lbs./ft. 8 in.To 5Oft. L3 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft.Todd in.To147ft. Wood n.To ft. lbs./ft. in.To ft. �R7[)C� SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make Johnson From ft. To ft. same • 2" Type stainless steel Diam. Slot/Gauze .010 Length 4' 4 4t Set between 137 ft.and 147 ft. FITTINGSZ3 STATIC WATER LEVEL 75 ft.,,{Below ❑Above land surface Date measured 2-17-19- Dry hole ❑ Yes al No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 130 ft.after 2 hrs.pumping 30 q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. � *h WELLHEAD COMPLETION a= /J1Pitless/adapter manufacturer t te= Model ❑Casing protection "12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_ m O To 50 ft. 3 ❑Yds. [Bags Material caatting From_501-0_13T 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 .i 0 NEAREST KNOWN SOURCE OF CONTAMINATION topsoil black ) 3 Well is .'71�') feet direction from '--y - -"'"----19136-- "'"typ8'- brown disinfected upon completion? . "Yes El No J -- clay brown medium 3 17 PUMP �q n q� ❑Not installed Date installed 2-22-19 clay gray medium 17 48 Manufacturer's reefer Model Number HP 1 Volts 230 sandy clay gray medium 48 67105 Length of drop pipe ft. Capacity g.p.m. reddish medium ow Type {Submersible ElL.S.Turbine ❑Reciprocating ❑Jet ❑ sand/gravel brown medi L �e ABANDONED WELLS fine sand brown soft '!9 103 Does property have any not in use and not sealed well(s)? ❑Yes klo VARIANCE . Sand t brown soft 103 147 Was a variance granted from the MDH for this well? ❑Yes,$'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,it needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. t Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business N.,e Lic.or Reg.No. 2-25-19 -e ' -d'epresentativ ,I ature Certified Rep.No. Date LOCAL COPY 839617 _ - Rob Stodola Name of Driller ID#52603 HE-01205-17(Rev.5/17) F MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 2 8 9 4 WELL OR BORING LOCATION Sealing No. CountyrJame WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or W W-a eries No. not known) Towns ip amii Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed 11 Orono 117 23 06 N TA - a//8 hi GPS LOCATION—decimal degrees(to four decimal places) • Depth at Time of Sealing / ft. Original Depth ft. Latitude Longitude RA IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer Ill Multiaquifer 480 Park Ave, Orono 55356 WELL/BORING Measured Date Measured /jIL � ❑Estimated Water-Supply Well ❑Env.Well r Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property ❑Temp.Env.Well ❑Other _ S ft. 'below ❑above land surface lines,roads,and buildings. N CASING TYPE(S) e Steel ❑Plastic ❑Tile ID Other .__1___.__a__ -----:___ 4 WELLHEAD COMPLETION W E T �t` t I I Outsider Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset il ❑Other❑Well Pit ❑Buried ❑Well House ❑Well Pit s ❑Buried I 1 Mile—❑ ❑Other For multiple temporary environmental wells,p vide addit nal location CASING(S) information,a site sketch,and geology on a swarate page. DiamEt�r� / Depth / Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME X77// in.from 0 to_4562_ft. ❑Yes KNo ❑Yes ❑No ❑Unknown Props ow�rs mar ddress if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown SCREEN/OPEN HOLE r I WELL OWNER'S NAME/COMPANY NAME Screen from 40_to/GPO ft. Open Hole from to ft. OBSTRUCTIONS Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑FillNo Obstruction Type of Obstructions(Describe) Obstructions removed? ❑Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ;KNot Present Present,Removed Prior to Sealing FORMATION �l ❑ El Other ,,,...,..e If not known,indicate estimated formation log from nearby well or boring. Type d 0 ii„, METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE V uu ro Annular Space Exists ❑Annular Space Grouted with Tremie Pipe El Casing Perforation/Removal sing Diameter in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ___ VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) / /_ I Grouting MateriayI�r /2i4 ( /Tfrom� to/6o4) ft. yards 43 bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑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. ',� .3 / 9 C- I, -e.resen ative Signature Certified Rep.No. Date LOCAL COPY H 3 6 2 8 9 4 Name of Person Sealing Well or Borin \ CYw HE-01434-16 ID#53159 f 9/1711 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: 19-02037 Twin City Water Clinic Inc. Sample Collection Date: 02/17/19 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 14:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 02/18/19 Phone: (952)935-3556 Report Issue Date: 02/20/19 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 19-02037 Coliform Drinking Water 02/18/19 12:31 Absent 19-02037 Nitrate/N Drinking Water 02/19/19 12:40 <1.0 mg/L 19-02037 Arsenic Drinking Water 02/18/19 9:15 02/20/19 10:25 3.30 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L E.coli Drinking Water Well No.: 839617 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample Pt: well laboratory. [Laboratory name;address;MDH Lab ID#). The Well Adr: 480 Park Ave;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Todd Wood field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 6 'C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: SM9222B-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml EPA 353.2 Nitrate Nitrogen expressed as NO3+NO2,1.0 mg/L Nitrate Nitrogen 10.0 mg/L SM3113B-Arsenic,2.0µg/I,Lead,2.0 µg/L Arsenic,10.0 µg/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Lead,15.0µg/L Nitrite,1 mg/L Sample Collected by: X Client TCWC Approved By: 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