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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AEND BORIN'�G NO. ELL County Nam� WELL AND BORING RECORD 7 g 3 5 0 3 `�p�� Minnesota Statutes,Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMP�ETED 4cbno 117 23 0� N� �W��NW �� 291 n 3—t7-11 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ . Longitude degrees minutes seconds _�Cable Tool � �Driven � '��Dug �i Auger ',�'�totary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� 2J(7 L P1SL`e vL� 5535b DRILLING FLUID WEL�HYDROFRACTURED? I I Yes �'No Show exact location of well/boring in section rid with"X" Sketch map of welUboring location. '�^"'�""'�"'� From ft.To ft. Showing property lines, road�,buildingS, nd direction. USE N �, �� [�f Domestic Monitoring ❑Heating/Cooling � � � : i. ��R,��. ..._. -. ,,�\_P,,,,a„� _ __;__ ;___ __� __,_ � ' '� Noncommunity PWS ��Environ.Bore Hole [ ]Industry/Commercial Community PWS �]Irrigation � !Remedial --- ----- ----- --- - �"�� \ � 1 .J Elevator ;_'Dewatering _., _ J _ I : : . \ - w ; ; ; ; e � '\„�_j� CASING MATERIAL Drive Shoe? U Yes �No HOLE DIAM. --,--- --�----�-- ---�-- T -�� ;Steel i�Threaded � J Welded , , � , '/Mile SIiC � ";___r____�__ � 1 ��. '�Pla �,�(�% CASING S � .. ,,y Diameter Weight Specitications �_�M�,ie� _�___in.to.___�.�fl �Ibs./ft. _.. �__in.to�' t. PROPERTY OWNER'S NAME/COMPANY NA E .in.to _.__ft. Ibs./tt. __ �in.to_��ft. s�� in.to ft. IbsJft. in.to____ ft. �� 'L� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN_ Make _�� _ From ft. To._._,..... . ft. � Type��_=�'��8 � Diam. - — -- _ _�—� +� SIoUGauze •�� g � � . ----------Len th _.- - Set between__�,��__ft.and__Z�I iL FITTINGS_2��~ STATIC WATER LEVEL � Measured from _.��___ ft.,�Below ❑Above land surface Date measured__�j,7+■�� . WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after_�_ hrs.pumping__�_. _g.p.m. � Weltlboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,,y� �PiUess/adapter manufacturer�yiyt�=�r Model___ _ �Casing Protection ._ _._ _.___._ ��12 in.above grade �� (�At-grade(Environmental Well and Boring ONLY) GROUTING WFORMATION Well�� . �No �� Grout�n„�t@r 11�,�,f Ney�t�qrn�nt�enlonite�,qConcrete [�Other �, T�3CUC8S1 T 11 a 1t�4 From_ To. ft [�Yds. ❑Bags HARDNESS OF From_ To ___ft. �,-;Yds �—�.gags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� - From To ft. ❑Yds. U Bags NEAREST KNOWN SOURCE OF CONTAMINATION ,��,..� �(/f __.-� . �� Z �� 0 J�.J�..✓ feet !`� _direction� �''"-'l� Well disinfected upon completion? 7{'Yes � �No ^-- C�S � �� PUMP .. - Not installed Date installed ��S'�l� � f�� `� Manufacturer's name �fer Model Number HP �!� Volts 4.7V �� Length ot drop pipe�'�� ft. Capacity g.p.m. Type�Submersible � ��LS.Turbine � �Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ^��.Yes.�;No VARIANCE Was a variance granted irom the MDH for this well? �_�Yes..�f 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. �bn Stodols WeII �Xillfc�g Co., Inc. �69I Licensee Business Name Lic.or Reg.No. � � .f,. 8—It}-lI e ed F(epresentative SignatJre Certified Rep.No. Date Ji� IGohl.a !! LOCAL COPY 7 8 3� � 3 Name ot Driller IC 140-0020 H601205-12(Rev.72/08) � Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 CI1211t: Don Stodola Well Drilling Co Report Number: ii-oa61 Twin City Water Clinic Inc. Sample Collection Date: on/ii/is 617 13th Avenue South ACICII'255: 3841 North Main Street Sample Collection Time: ia:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: oa/iz/ii Phone: (952)935-3556 Report �ssue Date: oa/i3/ii Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 11-02986 Coliform Drinking Water 04/12/11 13:38 Absent 11-02986 Nitrate/N Drinking Water 04/12/11 11:54 65.36 mg/I i1-02986 Arsenic Drinking Water 04/12/11 8:45 04/13/11 11:33 <2.0 µg/I Lead Drinking Water µg/� Drinking Water Drinking Water Drinking Water X No samples were subcontracted;or the above test result(s) Sample Conditions/Discussion/Notes: with'**'designation were produced by a subcontracted laboratory. Sample Location-Well#783503 Tom Lutz 258 Cygnet Place Orono,MN (Laboratory name;address;MDH Lab ID#j. The subcontracted laboratory maintains MDH Certification for the field(s)of testing performed. Sample Temperature: 9 °C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the samples This Sample does not listed above have the following reporting levels: Maximum contaminant levels: meet the State Af SM92226-Coliform, 1 cfu/ 100 ml Coliform-<1 cfu/100,ml Minnesota,Wisconsin Nitrate Nitrogen 10.0 mg/I SM4500D- Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.0 µg/I and EPA guidelines for SM 3003-Arsenic, 2.0µg/I Lead, 15.0µg/I safe drinking water for SM3113-Lead, 2.0µg/I the analytes tested. ,� � � , :�.�.:��.� , �'�,� / �. � _. 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 DEPARTMENT OF HEALTH Minnesota Well and Boring �Q��O WELL OR BORING LOCATION Sealing No. H J County NamA► WELL AND BORING SEALING RECORD Minnesota Unique Well No. � ' Minnesota Statutes,Cha ter f03I or W-series No. P (Leave blank il no�known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �j_� � - �� tik�ownl GPS Latitude degrees minutes seconds Depth Before Sealing � O�� ft. Original Depth t p�,��f' 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 [ J Multiaquifer �f�� _ f i o L WELL/BORING �Measured ❑Estimated Date Measured 1 � ZSC� P � 4 I'�,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 J Env.Bore Hole ❑Other �Q fl. �below ❑above land surface N lines,roads,and buildings. CASING TYPE(S) --'-- --j--- ---`-- ---'-- ' ,. Steel ❑Plastic ❑Tile [_.I Other � � , � > . � � � � •- � ' --'--- --�------�-- ---�-- WELLHEAD COMPLETION : W � � � � E ' ______ ______ ___;_ ___�__ T ` Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset i 'h M�ie �Pitless AdaptedUnit ❑Buried ❑Well Pit � --�-----T-- —�-- --�-- I e i , , , ' L �i ❑W II P't ❑Buried � � S , � � F--1 Mile--� � ❑Other ❑�ther � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter Depth Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different ihan well location address indicated above !J a 7 in.from .J to �Ot � ft. ❑Yes �,No ❑Yes �No []Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No LJ Unknown in.from to ft. ❑Yes ❑Na ❑Yes ❑No �l Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Well owner's mai�ing 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 �]No Obstruction � Type of Obstructions(Describe)_ �� GEOLOGICAL MATERIAL COLOR HARDNESS OH FROM TO Obstructions removed? �Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. t� � \-�r,� �TYPe S�.�3 �Removed ❑Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �j,No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed - in.from to ft. ❑Perforated i__�Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material{V�p7 L��r�nT,,om_Q_ to �a 5 ft. yards 'Q 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. Dc�ci Stcxit�la Well Drillir�, co., Ir�c. 1b92 _ � Licensee Business Na License or Registration No. - �- � /�/ t � erG' d presentative Sign Certilied Rep.No. Date LOCAL COPY H 2 9 3 5 5 0 � ' Name of Person Sealing Well or Boring HE-01434-12 IC#140-0423 9/09R