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Home My WebLink AboutWell & Boring const. record & sealing record t i. MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD 810 8 6 8 Hennepin Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMlR�C Ea,,` _ Orono 117 23 04 NE NW's SE ,� 122 n. 5-6-1,,5`` vt GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD SEP' — Latitude Longitude ❑Cable Tool Driven N 2015 ❑Auger Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other ®E 2715 White Oak Crl, Orono 55356 DRILLING FLUID WELL HYDROEDOQ Show exact location of well/boring in section grid with"X." Sketch mf p of well/boring location. bentonite From ft.To ft. �o dy Showing property lines, N ro dings,and direction. USE M Domestic ❑Monitoring ❑Heating/Cooling ----L ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial .1' ❑Community PWS ❑Irrigation ❑Remedial ------- --- ---F --- - ❑Elevator ❑Dewatering ❑ w E T Drive Shoe? ❑Yes No CASING MATERIAL 'HOLE DIAM. ❑Steel ❑Threaded ❑Welded I.:Mile i , $Plastic ❑ o CASING s Diameter Weight Specifications —1 Miie 4 in.To 116 ft. lbs./ft. _in.Tot. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To 125t. in.To ft. lbs./ft. in.To ft. Steve Jenniges OPEN HOLE Property owner's mailing a dress if different than well location address indicated above. SCREEN Make Johnson From ft. To ft. same Type stainless steel Diam. 2" Slot/Gauze •01.0 Length 4' + 4' _� STAbetweenTICWAT ft.and 122 ft. FITTINGS 2"x3* leader v kp STATIC WATE L Measured from 6R ft.❑Below g Above land surface Date measured 5-6-1.5 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 122 ft.after 2 hrs.pumping 30 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION f]Pitless/adapter manufacturer it7}'27_tewater Model ❑Casing protection S 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentonite�From 00 • To 50 ft. 3 El Yds. 'Bags Material natural ffr l—50-, 116 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLORmediumMATERIAL FROM TO Driven casing seal From To Bags O NEAREST KNOWN/ SOURCE OF CONTAMINATION� topsoil black / O feet /�' direction (1,__9-••-,-4 .—)--'-`Mae— clay yellow altdium 3 22 Well disinfected upon completion? Yes ❑No _,/�ti�C o L i- -� • PUMP sandy clay gray medium 22 49 ❑Not installed Date installed 5-13-'15 Manufacturer's name used existing sand/gravel brown medium 49 122 Model Number HP 1 Volts 1 Length of drop pipe !.�1/ ft. Capacity g.p.m sandy clay red medium 1 22 125 Type:$Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED 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 igi 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 Busines Name Lic.or Reg.No. / / 7-28-15 ertified Representative ignature Certified Rep.No. Date Rob Stodola LOCAL COPY 810868 Name of Driller IC 140-0020 - HE-01205-15(Rev.8/13) 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: 15-05179 Twin City Water Clinic Inc. Sample Collection Date: 05/06/15 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 14:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 05/07/15 Phone: (952)935-3556 Report Issue Date: 05/08/15 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 15-05179 Coliform Drinking Water 05/07/15 15:31 Absent 15-05179 Nitrate/N Drinking Water 05/08/15 13:46 <1.0 mg/L 15-05179 Arsenic Drinking Water 05/07/15 8:00 05/08/15 12:02 3.93 µg/L Lead Drinking Water pg/L Nitrite/N Drinking Water mg/L Drinking Water • Drinking Water Well No.: 810868 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#1. The Well Adr: 2715 White Oak Circle;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Steven Jen niges field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 9°C Discussion: Notes: Approved methods used in analyzing the samples listed Maximum contaminant levels: above have the following reporting levels: Coliform-<1 cfu/100 ml SM9222B-Coliform,1 cfu/100 ml Nitrate Nitrogen 10.0 mg/IL SM4500F or EPA 353.2-Nitrate Nitrogen,1.0 mg/L Arsenic,10.0 µg/L SM3113B-Arsenic,2.0 pg/I,Lead,2.0 µg/L Lead,15.0p.g/L EPA 353.2-Nitrite Nitrogen,1.0mg/L Nitrite,1 mg/L Sample Collected by: X Client _TCWC Approved By: Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst 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 2.0 Page 1 of 1 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 329482`�9 4 C� 2 WELL OR BORING LOCATION WELL AND BORING SEALING RECORD SS aliing Na County Name Unique Well No. L lJ Hennepin Minnesota Statutes,Chapter 1031 or W W-series No. Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 04 N6 Nei SE 4, AUG 'S GPS LOCATION—decimal degrees(to four decimal places) Depth Before Sealing /i/ ft. Original Depth ft. Latitude Longitude AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or BoringLocation Single Aquifer ❑Multiaquifer 2715 White Oak Cr1, Orono 5356 `1tjFLUBORING jg Measured ❑Estimated Date Measured snity Vf4/ .a Water-Supply Well ❑Monit.Well r Show exact location of well or boring Sketch map of well or boring ❑Env.Bore Hole ❑Oed ther ft. below ID above land surface in section grid with"X." location,showing property ' ds,and bwldings. CASING TYPE(S) N •of ':- _.. I I ISteel [II Plastic ❑Tile ❑Other ---j--- --- WELLHEAD COMPLETION W ' EI T Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h Mile XPitless Adapter/Unit ❑Buried ❑Well Pit I I Ti i €5.,, ❑Well Pit ❑Buried S `n. ❑Other )--1Miley ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Ste{ie J e, Diameter r Depth ., Set in oversize hole? Annular space initially grouted? Property owner's mailin� g addh,3s it—different than well location address indicated above ��YY!! in.from 0 to ill ft. ❑Yes X No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE I l/ Well owner's mailing address if different than property owner's address indicated above Screen from ��/ to �� ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HFROM TO Obstructions removed? ❑Yes ❑No Describe FOR FORMATIONMATION PUMP If not known,indicate estimated formation log from nearby well or boring. ci,L,;ji `/��,Type O /'V ❑Removed Not Present El Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: 'lo 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 Ig io TN# GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Material/vie/4rC.//r=A''rrom Q to if/5" ft. yards 9 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 )(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 Well Drilling Co,. Inc. 1691 Licensee Bus, ss meLicense or Registration No. C fie d,4-aimi/ -we Sign- rr' Certified Rep.No. Date E LOCAL COPY H 329 4 8 2 Name of Person Sealing Well or Boring (/ `' "Nr--- HE-01434-14 IC#140-0423 5/138