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Home My WebLink About03-27-19 Wel & Boring Construction Record MINNESOTA UNIQUE WELL WELL-OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING Na County Name WELL AND BORING CONSTRUCTION RECORD 8 2 7 8 21 Minnesota Statutes,Chapter 1031 TownshipHennepinrvar Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 09 ' I' ?+ SB'' 224 3-27-19 _ GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool - ❑ even El Dual Rotary frri House Number,Street Name,City,and ZIP Code of Well Location ❑Ougerlotary ii Rotasonic ❑Other 2655 North Shore Dr, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes pkgo Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. water From ft.To ft. Showing property lines, - roads,buildings,and direction. USE N Domestic ❑Monitoring ❑Heating/Cooling _________ _____________- A O v „,--:.,_,k_,,�,_`g" ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial i - -- -- ElevatornityPWS ❑Dewatering Remedial ❑ ❑ w E • ❑ ❑ T �- CASING MATERIAL HOLE DIAM. Drive Shoe? ❑Yes Ne100 ❑Steel ❑Threaded ❑Welded /Mie >elastic ❑ ____ r ;_ I CASING 77 R Diameter Weight Specifications ) -1 Mile ( 4 in.To 205 ft. lbs./ft. - in.To SOt. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ff. 63/4 in.To 21St. LSI Custom Homes in.To ft. lbs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. 15101 Stone Ridge Trace Make Johnson From ft. To t Wayzata, MN 55391 Type stainless steel Diam. 2“ Slot/Gauze .010 Length 4, .. /_ Set between� �ft.and 214 ft. FITTING$.� 3 1 loader STATIC WATER LEVEL 35 ft.Nr6elow ❑AboveLland surface WELL OWNER'S NAME/COMPANY NAME Measured fromLEVE �Dpte measured 3-Z7i1 J Dry hole El Yes No PUMPING LEVE ow and surface�l G J 190 ft.after 2 hrs.pumping 60 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ZPitless/adapter manufacturer Whitewater Model Casing protection12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_bentonirem 0 To 50 ft. 3 ❑Yds. >63ags Material cutting§rom 50 To205 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ElBags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement Driven casing seal From To Bags or 50 lb .bentonite 1, NEAREST KNOWN SOURCE OF CONTAMINATION /� n clay brown medium 0 14 Well is �/.�5 feet (/t--) direction from C J- &'- e•- Well disinfected upon completion? y Yes ❑No ...i clay gray soft 14 50 PUMP ❑Not installed Date installed 4-15-19 sandy clay gray soft 50 177 Manufacturer's name Schaefer Model Number HP 1.5 Volts 230 clay/sand gray soft 177 204 Length of drop pipe 61 ft. Capacity g.p.m. sand/gravel mix medium 204 215 Type: Submersible ❑L.S.Turbine ❑Reciprocating El Jet ❑ ABA DONED WELLS 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 �lclo 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 SAbdola Well Drilling Co., Inc. 1691 Licensee Business Name Lic.or Reg.No. 5-15-19 ::::4kr",,,e,Wk-,: re Certified Rep.No. Date LOCAL COPY 8 2 7 8 21n..s. e....a_1 Name of Driller ID#52603 HE-01205-16(Rev.5/16) MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 5 5 5 9 5 WELL OR BORING LOCATION WELL AND BORING SEALING RECORD County Name SealinMinneg Na Unique Well No.Minnesota Statutes,Chapter 1031 or W-series No.(Leave blank;,not known) Hennepi n Township Name Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 09 NG? Nt S' ! /e1 i/R GPS LOCATION–decimal degrees(to four decimal places) r Depth at Time of Sealing 2 5 7) ft. Original Depth ft. Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location 'J Single Aquifer ❑Mulliaquifer WELL/BORING >vleasured Date Measured 5/4 m( b/Y ❑Estimated 2655 North Shore Dr, Orono 55391 ieWater-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring L! ❑ in section grid with"X" locatig[showing property ❑Env.Bore Hole El Other ft. ''below above land surface lines;[4a s,and buil N CASING TYPE(S) idat.t____ Steel ❑Plastic El Tile ❑Other ---;--- ---; --- WELLHEAD COMPLETION w E T 1---- �– Outside:''Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset ---h --- ❑❑WellHouse ' Ir 3 u '�`` ❑Well Pit ❑Buried ; – __, Well Pit El Other s ❑Buried F--1 Mile –I ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) MST (1Rtnm RSG Dia tej i / Depth / Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above in.from O to_230 ft. El Yes , No ❑Yes ❑No El Unknown 15101 Stone Ridge Trace in.from to ft. ❑Yes ❑No El Yes El No ❑Unknown Wayzata, MN 55391 in.from to ft. ❑Yes El No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , 2..S9 Well owner's mailing address it different than property owner's address indicated above Screen from to ft. Open Hole from to ft. ,OBSTRUCTIONS pp Rods/Drop Pipe ❑Check Valve(s) CIDebris ❑Fill ❑No Obstruction Type of Obstructions(Describe)...2/�/#,/1 f_r/ 4 'Cl/7'7i)� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ;(Yes 111No Describe I FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. El Not Present /� �Present,Removed Prior to Sealing ❑Other d p,:. ,...k- "23o Type $OP CUP1'f P 52L– ...- . ,g 2s-7 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE yr No Annular Space Exists ['Annular Space Grouted with Tremie Pipe El 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? El Yes No TN# GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) ,,�y r / Grouting Materia)4/ i9 C , 7 � from Q to 2531 ft. yards 28 bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS NK REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? El Yes y�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. Don Stodola hell Drilling Co, Inc. 1691 Licensee Business Nameff // License or Registration No. /:.; entBti a rgnature Certified Rep.No. Date 355595 `ng — , ,` -'� LOCAL COPY H Name of Person Sealing Well or Boring HE-01434-15 ID#53159 (1+ 8/16R 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: 19-03468 Twin City Water Clinic Inc. Sample Collection Date: 03/27/19 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 14:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 03/28/19 Phone: (952)935-3556 Report Issue Date: 03/29/19 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 19-03468 Coliform Drinking Water 03/28/19 12:12 Absent 19-03468 Nitrate/N Drinking Water 03/28/19 13:05 <1.0 mg/L 19-03468 Arsenic Drinking Water 03/28/19 10:00 03/29/19 12:32 2.51 µg/L Lead Drinking Water µg/L Well No.: 827821 X No samples were subcontracted;or the above test results) with'**'designation were produced by a subcontracted Sample pt: well laboratory. [Laboratory name;address;MOH Lab ID#]. The Well Adr: 2655 North Shore Dr;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: MSI Custom Homes field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 10°C Discussion: Notes: Sample did not meet method temperature/preservation requirements. 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 asNO3+N0e,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