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Home My WebLink AboutWell Record - Dated 12-12-15 � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD g,1 �0 0 4 Minnesota Statutes,Chapter 10.?I Towns ip a e Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED fl. '/ r GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHO Latitude Longitude ❑Cable Tool U Driven ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other 4565 Ba $1�� R�� OL�OYZO 55359 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. j��r From ft.To ft. .; Showing property lines, �, roads,byAgling�nd direction. USE �� Monitorin H `:' . N �._ � � Domestic ❑ g ❑ eating/Cooling �.. __j____j___ _!__ ___;_ � ' ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ` � ❑Community PWS ❑Irrigation ❑Remedial __�___ ._J..- -_�-- ---.-- �Elevator ❑Dewatering ❑ ' ; w ; ; ; ; E T CASING MATERIAL Drive Shoe? ❑Yes y�*(No HOLE DIAM. - --;-- --�-----F— --%-- �' I �J Steel ❑Threaded ❑Welded ..�� , de �h ��M Plastic ❑ � ------ -------------._ 1 � � � CASING S � Diameter Weight Specifications �---i nniie—� �in.To�,7�ft. Ibs./ft. � in.To�tt. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJft. ��.'�__in.Td.W ft. �nat j �t�i ��I[�$ ��• in.To ft. Ibs./ft. in.To ft. 1� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREE�Nt,,�. LLJ�� i�tirit� �1� Make..;ViR�i�'I� From ft. To ft. T�,�, Type�R�lt�PQt$ ;$t�� Diam. s.�Q�Q�T1� t� 553�1 SIoVGauze `M� Length J��./.FI Set between ft.and ft. FITTINGS � ., STATIC WATER L Measured from tL ��T R. Below ❑Above land surface Date measured 2 2'�l J WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) RECEII/ED i�7C� ft.after 3 hrs.pumping 30 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �l � �� Pitless/adaptermanufacturer�►t13.te�$ter Model Casing protection �12 in.above grade r]At-grade ❑Well House ❑Hand Pump /� �� GROUT WFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material 1,pnrnr�3 rakom�To_�Q_ft. � ❑Yds. rja'Bags Matenal__��_�r�r�_�To 1 Qi ft. �Yds. T�]Bags HARDNESS OF Matenal From To ft. ❑Yds. �J Bags ' GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION C1.8 bCOW11 1�d�L1t�T V �tl f� � teet `+� direction ~� '+�� type Well disinfected upon completion? Yes ❑Na S�:tiKl CZII nL'A ��.LX?3 �1J ��# PUMP 'L Not installed Date installed 1"'13-16 "raveUsand R1i.X 11Ie�i�) 9� �.�� Manufacturer's name Model Number HP_��_Volts sand bca�m r�di�n 120 155 Length of drop pipe �� ft. Capacity g.p.m , _Y�� r�V�� 3x �� C� �M Type: Submersible ❑LS.Turbine �]Reciprocating ❑Jet ❑ �� Li11L.! A � ��J 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 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 Seadois Weil Driilin�; Ca,. inc. 1691 Licensee Business Name Lic.or Reg.No. / s, �F.j'.�� J � ,,,,, � Z�2."`l� � . ., etd epr� ntative Signature Certified Rep.No. Date 818 0 0 4 Ro� st«to�a L�C./-�L C�PY Name of oriuer — ID#52603 HE-01205-15(Rev.8/13) � � r � , Minnesota State Laboratory ID#027-053-119 Twin City Water Clinic Laboratory Test Report w�s�o�5��state�anorator,,�oa�05-�0�� Wisconsin DNR Lab ID#399073400 Client: Don stodola well orilling Report Number: 15-14522 Twin City Water Clinic Inc. Sample Collection Date: 12/13/15 617 13th Avenue South Address: 3841 North nnain Street Sample Collection Time: 14:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 12/14/15 Phone: (952)935-3556 Report Issue Date: 12/15/15 Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 15-14522 Coliform Drinking Water 12/14/15 11:51 Absent 15-14522 Nitrate/N Drinking Water 12/15/15 11:35 <1.0 mg/L 15-14522 Arsenic Drinking Water 12/14/15 8:15 12/15/15 11:55 5.66 µg/L Lead prinking Water µg/L fSitrite/N Dr�.^.kl:�g�J�ldt2r, III��L Drinking Water Drinking Water Well No.: 818004 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: 4565 Bayside Road;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Denali Custom field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 14°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 SM92228-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,2.0µg/I,Lead,2.0 µg/L Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L ) /;� 7/,? .��L i�,� ;'./ � !�:.<.xs'.��.r.,Lt'�,c�-^/''. Sample Collected by: X Client _TCWC Approved By: � "� 1 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 foltowed,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