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Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119
Wisconsin State Laboratory ID#105-10117
CI1211L: Don Stodola Well Drilling Co Report Number: i2-iz�59 Twin City Water Clinic Inc.
Sample Collection Date: ii/i2/iz 617 13th Avenue South
Address: 3841 North Main Street Sample Collection Time:, is:oo Hopkins, MN 55343
St.Bonifacius,MN 55375 Sample Receipt Date: ii/is/ii Phone: (952)935-3556
Report Issue Date: 11/ia/i2 Fax: (952)935-5077
Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test
Sample ID Date Time Date Time Results Units
12-12769 Coliform Drinking Water 11/13/12 12:53 Absent
12-12769 Nitrate/N Drinking Water 11/13/12 13:42 <1.0 mg/I
12-12769 Arsenic Drinking Water 11/13/12 9:30 11/14/12 16:15 2.49 µg/I
Lead Drinking Water µg/I
Drinking Water
Drinking Water
Drinking Water
Well No.:
X No samples were subcontracted;or the above test result(s)
with'**'designation were produced by.a subcontracted Sampl2 pt:
laboratory. [Laboratory name;address;MDH Lab ID#].The Well Adr: 4495 Bayside Rd,Orono,MN
subcontracted laboratory mainfains MDH Certification for the Owner: Katherine Taylor
field(s)of testing performed.
Owner Adr:
Sample Conditions:
Sample Temperature: 11 °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
Nitrate Nitrogen 10.0 mg/I
SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.0 µg/I
SM3113B-Arsenic, 2.0µg/I Lead,15.0µg/I
SM31136-Lead, 2.0µg/I
, ,) ;i ,
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�,%." , � ��,�3.u..rc -�car fi"f
1 V:�
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 1.2 Page 1 of 1
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MINNESOTA UN/QUE WELL
= WELL OR�30f,ill`J�LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. r
� Counry Name WELL AND BORING RECORD 7 g 19 9 9
Minnesota Statutes,Chapter f037
To n Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
� �.17 �� �! �+ �� v, ��� n �. �
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude degrees minutes seconds �'Cable Tool ❑Driven
J Auger �Rotary
House Number,Sireei Name,City,and ZIP Code of Well Location Fire Number ��Other
6495 B� �� E�1 {#cano 55�59 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. �R+=�u�e From.. ft.To ft.
Showing property lines, ---
: N road ,buil 'ngs.and direction. USE �omestic ❑Monitoring ❑Heating/Cooling
' I � � I '`.F_;�X �;,J,...� .
__..__ . _�_ __.__ �_]Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
; � � � �
�� [..]Community PWS ❑Irrigation , ❑Remedial
' --'-----�-- --`—--`— [ !Elevator �Dewatering � ❑
? `N , , ; ; E " ASW ERIA rive Shoe? �Yes �,� No HOLE DIAM.
C GMAT L p
� --�-----�------�-----�-- � :
s I I I I
T � ,�Steel �Threaded ❑V�Ielded
:� , , , , '!�Mile
�' --�---—�--- --�----�- ❑Plastic [ :
�� CASING
� � S � � � ,(�, Diameter Weight Specifications
�J� Q
��Mite� � in.To�� ft. Ibs./ft. v in.To �O ft
'' PROPERTY OWNER�S NAMErCOMPANY NAME in.To_.._. . tt. Ibs./ft. "� in.Ta�+�ft ._
' -��-----...__,_ in.To ft. Ibs./ft To ft t
- �C��� TS lOC� �S �QC• OPEN HOLE
Property owner's mailing address if different than well location addr s i`icated above. SCREEN _
14S RS�.LW�y St C�I Make t� __ __ From ft. To ft.
���t� 1� 55357 Type__ Dia�
! SIoUGauze��(� _____ Length_�t
Set between ""'ft.and ft. FITTINGS
" STATIC WATE L �
Measured rom
� ft.�{Below ❑Above land surface Date measured
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
ft.after hrs.pumping_ g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
�Pitless/adapter manufacturer ��a�`�� Model
❑Casing protection �12 in.above grade
❑At-grade �J Well House ❑Hand Pump
GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Matenal_ om To ft ❑Yds. �_�Bags
�� � � �
Matenal���To�ft. ❑Yds. U Bags
HARDNESS OF Material . __ From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags
NEAREST KNOWN SOURCE OF CONTAMINATION
C�� iJLi7�YII �l� �� �.- feet � '� direction �— type
Well disinfected upon completian? �Yes ❑No �
;
Ci$ j'$ �(}�� � PUMP
; L Not installed Date installed__ Z�-13 '
�` 1 � ��� Manufacturer's name '����� � __
' * l`���.,,�J / Model Number HP__}.�.�__Volis
� Ca �� �i'L� Len th of dro i e__ ZV(7 ft. Ca acit m -
9 PPP P Y 9P
C�8 ' �� Type:�Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
ABANDONED WELLS
�itel °
Y�—t� Does property have any not in use and not sealed well(s)? ❑Yes I_�jCNo
acaiA�a �
VARIANCE
* ,��� Was a variance granted from the MDH for this we117 ❑Yes �No TN#
1 WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with fvlinnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,il needed.
REMARKS,ELEVATION,SOURCE OF DATA,etc. CE�yED
DcMi Sttxta►18 WeII Ih'illisi� Co., I�. !&91
J�� Licensee Business Name Lic.or Reg.No.
212Q13 "..--�
. _- . �,.
C�N O�'p ' � �--�t—��_ �
���0 C resen i e Siy�6fur Certified Rep.No. Date
LOCAL COPY 7 919 9 9 - �` '-���
Name of Driller
IC 140-0020 HE-01205-13(Rev.11/10)
_ � r """"
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �g Q 5 7 5
County Name
WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No.
Minnesota Statutes,Chapter 103! or W-series No.
Heanapin «ea�e o�a�k���o,k�ow�,
Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed
�' Orono 117N 23W 6 NE � I�W June 25, 2009
,
GPS Latitude____ degrees ____ minutes___ . seconds Depth Before Sealing �,v tt. Original Depth ft.
�� LOCATION: Longitude_ degrees_____ minutes seconds �'
—�--"-- AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location '��Single Aquifer ❑Multiaquifer 6/25/09
6695 Bayside �� 0r0110 SJ3V�i WELL/BORING [�Measured i]Estimated DateMeasured _ _
[�Water-Supply Well ❑Monit Well
Show exact location of well or boring Sketch map of well or boring r I Env.Bore Hole Other 130 ft. below above land surface
in section grid with"X." location,showing property ❑ — � ❑
f�,��� � lines,roads,and buildings. CASING TYPE(S)
; �
'� �'i� .������• �Steel [;Plastic L;Tle ❑Other
�
� --'-----'--- ---�---'-'"- WELLHEAD COMPLETION �
� W ; ; ; ET {j��
;� __;_____;____;___.r__ �^q Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset
'h Mae ^" [�i Pitless Adapter/Unit ❑Buried ❑Well Pit
' --j--- --�-----�-- --�— I ❑Buried
L ❑Well Pit
S ❑Other
�1 Mile--� �- '�"'»�� �� ❑OthBf
P OPE TY O NER'S ME/ OMPANY NAME CASING(S)
Gat�er�ne �a �or Homes
y Diargeter O Deptly,� Set in oversize hole? Annular space initially grouted?
Propert owner's mailing address if difterent than well location address indicated above 4 1
ib� Raiiway st W in.from to ft [�Yes ❑No �Yes ❑No ❑Unknown
Loretto. 1� 55359 in.from �o ft. ❑Yes
❑No ❑Yes �No �;Unknown
_____in.from to____ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Catheriae Taplor H�op[ 1 Q T
Well owner's mailing address if different than property owner's address indicated above SCreen ffom a�" to �`� ft. Open Hole frOm � to ft.
� r�,
OBSTRUCTIONS
z �Tnods/Drop Pipe ❑Check Valve(s) J Debris ❑Fill ❑No Obstruction
Type of Obstructions(Describe) drop pipe
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7 ��Yes ❑No Describe
FORMATION
. If not known,indicate estimated formation log from nearby well or boring. PUMP tr
Type �uV�f, _
., [�L'Removed ❑Not 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
L Other _
GROUTING MATERIAI(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
GroutingMaterial A@8t �em8I1C from � _ to 17� ft. yards i�' 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? J'Yes ',$No How many7__ ___ _
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.
Stevene Drilling � Bav. Svc. Znc. 2255
ic see Business Name License or Registration No.
, � �. , 556 6/29IQ9
c�— ------__---- — ,
ed Representative Signatur Certilied Rep.No. Date
' ---
H 2 80 5 7 5 Tim Stevene
`�`�, LOCAL COPY - --- __ _ _—— — �
Name ol Person Sealing Well or Boring
HE-07434-11 IC#140-0423 2iosR
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