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Home My WebLink Aboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnes�ota Well and Boring � �� WELL OR BORING LOCAT�ON Sealin No. H � � �o��,Y��r� � WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 1031 or W-series No. u^TA; �n � (L2ave blank�it not knowni ft��taiG �� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �?rono 117 23 �;�� "�" 'v�; i�Il�' J U�F �� GPS LOCATION- decimal degrees(to four decimai places) �.q � Depth Before Sealing �"' � ft. Original Depth ft. Latitude _ _._ Longitude _,_ _ --- FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Cit of Well or Borin Location ingle Aquifer ❑Mul�iaquifer Y 9 �--�i�f /� 2450 Countrysi�e �C� ��OTlt1 55356 WELUBORING Measured ❑Estimated DateMeasured_ -j�''�K `.J�� ,�Water-Supply Well ��Monit.Well ` � Show exact location of well or boring Sketch map of well or boring �� in section grid with"X° location,showing property ❑Env.Bore Hole ❑Other _ __ � R. �below ;�above land surface .- � N lines,roads,and buiidings. CASING TYPE(S) --'-----'--- ---`-----'- �.�teel ❑Plastic U Tile ❑Other __. . _ _ --'-----'--- --`"----�-- WELLHEAD COMPLETION ` W ; ; : ; ET ' ' � � Outside: � 'Well House ,_:At Grade Inside: ❑Basement Offset - - ----- -- -- --- -- , , , , � Mile W� �itless Adapter/Unit �J Buried ❑Well Pit '� J� - --.-- --,-- --�-- ---:-- l ❑Buried � S ` .�,Well Pit �� ❑Other �1 Mile—� 'y � �.�OfhBf_ __ .. �-��._' ,v_� �--�..� �..4`. PROPERTY OWNER'S NAME/COMt�PA..N,Y, NAME CASING(S) Lorriane �{��t�.'ti[lu�n Diame �� Depth � Set in oversize hole? Annular space initially grouted? �.l � Property owner's mailing address if different ihan well location address indicated above in.frOm_�__ to�ft � �Yes �lo ❑Yes NO ❑ ❑Unknown in.from to ft. ',Yes U No ❑Yes ��No ❑Unknown in.from to _ft �_]Yes '�I No ❑Yes ❑No ❑Unknawn WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � r Well owner's mailing address it different than properry owner's address indicated above Screen from ��t0 ! �, ft. Open Hole from to _ .._ft. - OBSTRUCTIONS (_�Rods/Drop Pipe �Check Valve(s) �'Debrls ',_,FIII �o Obsiruction Type of Obstructions(Describe) ____ _ ____ _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? [__.Yes �, i No Describe FORMATION If not nown,indicate estimated formation log from nearby well or boring. PUMP � � ic"1 t TYPe — — � Removed I�Not Present ❑Other f METHOD USEDTO 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 � No TN# GROUTING MATERIAL(S) (One bag of cement=94 bs.,one bag of bentonite=50 Ibs.) ^� M ��J''' / /(� / � �+j Grouting Material ��!'f,/ �/!/F/'v�from Q to / / ft. yards_,_ " "" bags from to R. yards bags __ __ from to_.__.__ fl. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �]Yes �. o 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. I)on Stcxiola �•i Licensee Business Name � . � License or Registration No. � � .i - ,� _ ...�,�- . .�,;."- — , ., � ,�� - /y _ .y - � � ,. , ili R r senta�ive�gnature� Certilied Rep.No. Date LOCALCOPY - � � " 3 2 0 2 71 Name ol Person Sealing Well or Boring f"' \�� HE-01434-14 IC#140-0423 � ;" Si�sR Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drilling Co Report Number: ia-o5o13 Twin City Water Clinic Inc. Sample Collection Date: oe/oa/ia 617 13th Avenue South AdfICe55: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: o6/os/ia Phone: (952)935-3556 Report Issue Date: oe/o6/ia Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 14-06013 Coliform Drinking Water 06/05/14 12:46 Absent 14-06013 Nitrate/N Drinking Water 06/05/14 12:42 <1.0 mg/I 14-06013 Arsenic Drinking Water 06/05/14 10:45 06/06/14 11:31 <2.0 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water Well No.: 799046 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: laboratory. [Laboratory name;address;MDH Lab ID#].The Well Adr: 2450 Countryside Dr Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Lorraine Kretchmann field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 15 °C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: SM92226-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 . ;� / �? � /j_�/t,, 'L.�,� � ' �f��.t.L.2�,N-Ot'f� 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 � � � --- MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. CountyName WELL AND BORING RECORD � �. Minnesota Statutes,Chapter 1037 - � ��`j �� Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED /. '/< �.`�� n —l�� GPS � ` � " DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds [i Cable Tool ❑Driven � Auger �otary House Number,Street Name,City,and ZIP Code of Well Location [�Other 2`^rSE! C�RS!ICLyS�� i�.� vL�OI�O 55355 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X' Sketch map of well/boring location. From tt.To ft. Showing property lines, N roads,buildings, nd direction. USE �f,omestic !�Monitorin ,Jx��, g ❑Heating/Cooling � _:___ __1__ ___L__ ___:__ ❑Nonwmmunity PWS ��l Environ.Bore Hole ❑Industry/Commercial �� ❑Community PWS ��Irrigation ❑Remedial � --'--- --'--- ---`-- ---`-- ❑Elevator ❑Dewatering ❑ ' ��: '�'� ; , , ; E CASING MATERIAL Drive Shoe? �]Yes � No HOLE DIAM. � � T � --.-- --.--- --�----.- , ' �� ❑Steel ❑Threaded [�Welded �J � � � � Mile 1 O D amleter Plastic L 1 � --�-----�-----�-----�-- .� g � �, Weight Specifications .11 ' r` F-1 Mile� �•:--t_;.. -, ?•,_.,--,� ?-�.. �,/a.. —4—in.To_�ft. Ibs./ft. _�in.To G n_ft JZ7 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft Ibs./ft. �;_in.T(i_��ft �,,�^ 4 Iarrisne Kr�tC+A!Kin in.To ft Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make � From ft. To ft. �c'31`r7� S�$ T! @S$ �tf.'�'e Diam.� Type_ SIoUGauze Length Set between �ft:an ft. FITTINGS STATIC WATE C L X � Measured�rom �j� _fL�3elow �]Aboveland surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �7� n 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 ��t�� _ Model ❑Casing protection �r 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTING INFOFIMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) - Material>>,.,.�cin3i«From n To�ft. � ❑Yda �Bags —�T Material�_a�i�prp�To�ft. ❑Yds. ❑Bags S I HARDNESS OF Matenal From To tt. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION to�soil hlack PrT@C��1$Ti � � _ � (� feet F� '—'J direction �. �.s type L Well disinfected upon completion? es []No 3�[lCj�i CZ$� s.7LOWi} T�ICIL'�'1 �I �,fj PUMP ❑Not installed Date installed ��a�.�.(F ga�y C��y ''L'� �d�� 12� Manufacturer's name :iC�'1€f�f(?j" Model Number HP 1.5 Volts �3� s�nc1/clay �•ra r�it�m 1?� 14'.-3 t G Length of drop pipe i�(�' ft. Capacity g.p.m �Cl�� C1$� r� ,„,�� I�n �� Type;,�Submersible [�J LS.Turbine ❑Reciprocating ❑Jet ❑ sttC^! � ABANDONEDWELLS ��/Lsl$� �ra. _,,,�a�j� ��f_ �� Does property have any not in use and not sealed well�s)? ❑Yes .�No ' �dK:IA sf F VARIANCE '�'�K�,7 ��,� ceddish P.�dir� i 75 1�(� Was a variance granted from the MDH for this well? ❑Yes � No TNIt WELL CONTRACTOR CERTIRCATION � This welf 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. �AV�t Use a seco�t,il needed. L`QLjr$e �� REMARKS,ELEVATION,SOURCE OF DATA,etc. t)an Stodola �de21 �cilli = Co . Licensee Business Name Lic.or Reg.No. � /' �`� � � Certified Representative Signature Certified Rep.No. Date j P,ob Stodola " 4�,� �'��4 � �OCAL GQPY � _ ." �,.F Name of Driller IC 140-0020 - � � HE-01205-14(Rev.5/12)