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Home My WebLink Aboutwell info WELL OR BORING LOCATION 4 ,51 3MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 32 9 5 1 WELL AND BORING SEALING RECORD Minnesota Sealing o County Name Unique Well No. �} Minnesota Statutes,Chapter 1031 or W-series No. Men p (Leave dank II-known) ne in Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed Orono M . Z% fy)AY 15'� GPS LOCATION—decimal degrees(to four decimal places) c Depth Before Sealing ft. Original Depth ft. Latitude Longitude p�piU IFER(S) STATIC WATER LEVEL MY OF ORON Numerical Street Address or Fire Number and City of Well or Boring Location Xingle Aquifer ❑Multiaquifer �./f��,J WELUBORING Measured ❑Estimated Date Measured r 2420 Watertown Rd Orow 55355 >'Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring r--Env.Bore Hole Other ft. below above land surface in section grid with"X" location,showing property ❑ ❑ ❑ N lines,roads,and buildings. CASINGTYPE(S) Steel E]Plastic El Tile ❑Other 07%-- -------- --- ------ T WELLHEAD COMPLETION W EI Outside: ❑Well House ❑At Grade Inside: E]Basement Offset 'h Mile 0 XPitless Adapter/Unit ❑Buried ❑Well Pit - -- -- ------ ��,� Buried 1 ❑Well Pit ❑Other 1 Mile A ❑Other -� LA-)i ,f„j PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) T Diam er • Depth Set in oversize hole? Annular space initially grouted? I Property owner's mailing address if diff rent than well location address indicated above . 'tin,from U to ft. ❑Yes XNo ❑Yes ❑No ❑Unknown C in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE / ) t Well owner's mailing address if different than property owner's address indicated above Screen from l r to175 ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ji Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? E]Yes ❑No Describe FORMATION PUMP If not kirlown,indicate estimated formation log from nearby well or boring. • 0 77 � Type_ ❑Removed of Present ❑Other 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 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 of cement=94 Ibs.,one bag of bentonite=50 lbs.) Grouting Material 1V4or(f*11/-1 / from Q to ft. yards bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING .Other unsealed and unused well or boring on property? ❑Yes Wo 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. Ikon Stodola Well Drilling co.. Inc. 1691 Licensee Busingss fjlame License or Registration No. zvi e e In Signature Certified Rep.No. Date LOCAL COPY " 3 '9451 Name of Person Seating Well or Boring HE-01434-14 IC#140-0423 5/13R Icn,y OR BORING LOCATIONMINNESOTA DEPARTMENT OF HEALTH MIN ASND BORINGG NOELL Name WELL AND BORING CONSTRUCTION RECORD 810863 T It Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 7. Ornnn' 118 714 33 SE SE 203 4-22-15 �= GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD V co Latitude Longitude ❑Cable Tool ❑Driven ❑Auger Rotary N 07 House Number,Street Name,City,and ZIP Code of Well Location –'Other C Q2420 Warartilum -11 1 DRILLING FLUID WELL WELL HYDROFRA Ufjy ❑Yes No Show exact location of well/boring in sec ion d with"X:' Sketch map of well/boring loca bentonite I I rF Showing property lie From ft.To dRn roads,buildings,and direc on. USE N � �Domestic E]Monitoring ❑Heating/Cooling ___ __;_____ ;__ 1�- b ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial } ❑Community PWS ❑Irrigation ❑Remedial ❑Elevator E]Dewatering ❑ C — - --- v/ E T CASING MATERIAL Drive Shoe? ❑Yes )4 No HOLE DIAM. ' ❑Steel ❑Threaded ❑Welded 'h Mile ❑ ; 1 Plastic CASING S Diameter Weight Specifications 1 Mile � �.;_' gyp.,,.. [A�f„-- (� _4 in.To 1498 ft. lbs./ft. _8_in.To__W. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. v,�in.TO-207- Terri Kenworthy in.To ft. lbs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE same Make stainless $ From ft. To _ ft. Type Diam. Slot/Gauze Length 19 Set between_198_ft.and ?n_1_ ft. FITTINGS- ~ f _ STATfffER LEVEL (( Measured from _ ft.$Below F]Above land surface Date measured 5 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 190 ft.after hrs.pumpingP.P.M. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer whiteimter 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 neat cemgAt 0 To 50 ft. 3 ❑Yds. XBags MaterialnatrUall _30To 198 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. E]Yds. E]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To __Bags /r�� NEAREST KNOWN SOURCE OF CONTAMINATION topsoil black um 0 4 1 W# feet S direction c f v $ewer ype Well disinfected upon completion? Yes E]No `_, clay tan medium 4 13 PUMP E]Not installed Date installed 4-25-15 sandy clay gray 1381 13 54 Manufacturer's name Schaefer gravel/sand mix courlse 54 109 Model Number HP 3/4 Volts 2,3n 1 Length of drop pipe 147 ft. Capacity 9-p.m sandy clay gray diu111 09 152 Type: Submersible ❑L.S.Turbine ❑Reciprocating E]Jet El ,.,"7ed ABAN ONED WELLS Sand redish br m52 180 Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE sandy clay/gravel red 111ediumm 1n/80 Was a variance granted from the MDH for this well? E]Yes No TN# C7lJ 7�f WELL CONTRACTOR CERTIFICATION 1�,�. r� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. Use a secoM�sl sand needed. Mel iM 94 205 The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. Ton Stodola 'dell Drilling co.2 Inc. 1691 Licensee Business Na a Li or Reg.No. / it w _ ertifi d R esehtative Signature Certified Rep.No. Date LOCAL COPY 810863 Name of Driller Rob S todola IC 140-0020 HE-01205-15(Rev.8/13) ti 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: 15-04664 Twin City Water Clinic Inc. Sample Collection Date: 04/22/15 61713th Avenue South Address: 3841 North Main Street Sample Collection Time: 11:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 04/23/15 Phone:(952)935-3556 Report Issue Date: 04/24/15 Fax: (952)935-5077 LaboratorV AnalyteClient ID Parameter - Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units' 15-04664 Coliform Drinking Water 04/23/15 13:51 Absent 15-04664 Nitrate/N Drinking Water 04/23/15 12:16 <1.0 mg/L 15-04664 Arsenic Drinking Water 04/23/15 8:00 04/24/15 13:36 9.72 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water Well No.: 810863 XNo samples were subcontracted;orthe above test result(s) with'"'designation were produced by a subcontracted Sample pt: Well laboratory. [Laboratory name;address;MDH Lab ID#]. The Well Adr: 2420 Watertown Road;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Terri Kenworthy field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 6°C Discussion: Notes: Approved methods used in analyzingthe samples listed Maximum contaminant levels: above have the following reporting levels: Coliform-<1 cfU/100 mf 5M9222B-Coliform,1 cfu/100 ml' Nitrate Nitrogen 10.0 mg/IL' SM450OF or EPA 353.2 Nitrate Nitrogen,1.0 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 ,Sample Collected by: X Client _TCWC Approved By: ; L �f L`` ..... Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst The results listed in this reporfapplyonly 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 2.0 Page 1 of 1