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Home My WebLink About11/08/18 Well and Boring Sealing Record WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota Wt lI and Boring H 362799 NCounty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. � ppf Minnesota Statutes,Chapter 1031 or W s eriesk No. a /lag 5�3 TownsTi ricin Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed v. 0 1,17 23 06 8 S6 SR `I Aio he IF S - '7 - oma?G / 7GPS OC ION– decimaldegrees(to four decimal places) ,,, �j Depth at Time of Sealing / /( ft. Original Depth I / I ft. Latitude Longitude O IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 780 Lakeview w fir, Orono 55364 WELL/BORING XMeasured Date Measured �rnF MI/ ❑Estimated Lii1SCv1 `ng vLa7 Ske J JPF Water-Supply Well ❑Env.Well i Show exact location of well or boring Sketch map of well or boring in section grid with"X." location,showing proper ❑Temp.Env.Well ❑Other ft. below ❑above land surface N Ines,roads,and bu'Idl CASING TYPE(S) l l l 1 I j r ❑Steel X.lastic ❑Tile ❑Other ---'--- - --F------t--- , 1 WELLHEAD COMPLETION w E— J �7 Outside: itless Adapter/Unit ❑At Grade Inside: II]Basement Offset %Mie ❑Well Pit ❑Buried ❑Well House ❑Well Pit Ts l 1 ❑Other //e ❑Buried f 1 Mlle I ❑Other For multiple temporary environmental wells,provide additional location CASING(S) information,a site sketch,and geology on a separate page. Diameter r , Depth , Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME in.from 0 to (]3 ft. X Yes ❑No IWCYes ❑No ❑Unknown Prop clin Nara if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 18215 45th�AVeN, Ste D in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown ! ' Plymouth, T 55446 SCREEN/OPEN HOLE /� WELL OWNER'S NAME/COMPANY NAME Screen from /61 to/// 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 ❑Fill ❑No Obstruction Type of Obstructions(Describe)Zili1/tie # 2' ¢ Ano Obstructions removed? )(Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO FORMATION ❑Not Present Present,Removed Prior to Sealing ❑Other If not known,indicate estimated formation log from nearby well or boring. Type dfrift 0 1 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal Casing 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 o TN# GROUTING MATERIAL(S) (One bag ofofcement= 4 lbs.,one bag of bentonite=50 lbs.) Grouting Material��A7ef /from .Q/ to /NW ft. yards /511/ bags from 'i to ft. yards bags i from ) to ft. yards bags OTHER WELLS AND BORINGS ! Other unsealed and unused well or boring on property? ❑Yes' No 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 billing Co, Inc- 1691 Licensee Business Name License or Registration No. ert"d" .re a i wig -ture Certified Rep.No. Date H 362799 Jim Antoni' LOCAL COPY Name of Person Sealing Well or Boring HE-01434-16 ID#53159 9079 4 _ , , - MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD 44 D Minnesota Statutes,chapter 1031 8 3 9 614 Township Name Tt unship No. Range No. Section No. Fraction(sm.—Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 SS::8E1/4SW"s 210 it 1-9-19 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD ir Latitude Longitude ❑Cable Tool Xis/en ❑Dual Rotary ❑Auger otary ❑Rotasonic House Number,StreetName,City,and ZIP Code`�{1W►ell Location +� ❑Other / 780 Lakeview Parkway, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes IJFNo beShow exact location of well/boring in section grid with" " Sketch map of well/boring location. jte T Showing property lines, From ft.To ft. r ads,buildings,and direction. USESo ❑Monitoring ❑Heating/Cooling MI1111111 J ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial BINEIll O CommunityvatoPWS ❑Irrigatteri ❑Remedial ❑Elevator Dewatering❑ ,,��SS❑ wBINEI E • CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. Steel ❑Threaded ❑ elded �� Plastic ❑ CASINGm Diameter Weight Specifications I 1 Mile "�' p �✓ in.To ft. lbs./ft. �_in.To, t. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. in.To_ 01. Norton s n.To ft. lbs./ft. in.To ft. OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN Johnson }18215 45th AVe Nil Ste D Make stainless steel From 2" ftL.Type Diam. To ft. Pl�th, MN 55446 Slot/Gauze .010 Length 41 + 4* Set between 200 ft.and 210 ft. FITTINGS 21I 1entitar STATIC WATER LEVEL" 75 ft. Below ❑Above land surface Date measured 1- -19 Dry hole ❑Yes No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 195 ft.after 5 hrs.pumping 35 q.p.m. Well/boring owner's mailing address if different than property owners address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer Tildieftwatar 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 bentonitfrom 0 To 50 ft. 3 ❑Yds./Bags Material cutting FromTo—liar 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 medium KNOWN SOURCE OF CONTAMINATION — m Clay brawn edium 0 15 Well is 4/:—.7— ( .',.z�''t9Pe 15 feet direction from clay gray medium 55 Well disinfected upon completion? X Yes ❑No •— • '>.& clay/sand graysoft]a55+ 70 62 PUMP sandy clay gray medium 62 ❑Not installed Date installed -19 sped/gray el mix soft 9070 90 Manufacturer's name Schaefer fine sand brown brown soft174 Model Number HP 4 1.5 Volts 230 silty clay/sand174 brown medium 199 Length of drop pipe 105 ft. Capacity g.p.m sand/gravel mix soft 199 210 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABA ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes;ONo VARIANCE 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. 6-17-19 °-°:-,Ze: erti epr sentative Sig(ature Certified Rep.No. Date Rob Stodola LOCAL COPY 8 3 9 614 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#10540117 Wisconsin,DNR Lab.ID.#399073400 Client: Don Stodola Well Drilling Report Number: 19-00393 Twin City Water Clinic Inc. Sample Collection Date: 01/09/19 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 15:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 01/10/19 Phone: (952)935-3556 Report Issue Date: 01/11/19 Fax: (952)935-5077 Laboratory Analyte;; Client ID Parameter, Sample Prep ..Sample Analysis Test sample'ID Date Time ` Date ' Time Results Units.- 19-00393 Coliform Drinking Water 01/10/19 13:41 Absent 19-00393 Nitrate/N Drinking Water 01/10/19 13:36 <1.0 riig/L 19-00393 Arsenic Drinking Water 01/10/19 12:05 01/11/19 12:10 6.95 tg/L Lead Drinking Waterg/L Nitrite/N Drinking Water mg/L E.coli Drinking Water Well No.: 839614 X:No samples were subcontracted iti the above test results) designation were produced.by a subcontractedSample pt: Well laboratory, [Laboratory name;:address;:MDH Lab-ID#). The;; s Well Adr: 780 Lakeview Pkwy;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Norton Homes fields)of testing performed Owner Adr: Sample Conditions: Sample Temp: 8 °C Discussion: Notes: Approved methods used ih analyzing the samples listed above have _ - th`e following reporting levels Maximum contaminant levels: 5M9222B Coliform 1 cfu/100 ml ' Colifoi'rh <1 cfu/100 ml EPA 353 2-Nitrate Nitrogen expressed as Nb9+Not,1 0 Mg/ Nitrate Nitrogen 10 0 mg/L- L SM31136 'Arsenic"2 0 /I Lead,2 0 L Arsenic 10r0 µg/L µPQ. Lead,15 0µg/,L EPA 353.2:-NitriteNitrogen,1 0 mg/1_ „ Nitrite;!1 mg/L '. Sample Collected by: X Client TCWC Approved By: 0 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 Thisanalytical 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 . . • ‘ . •-' -7'