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Home My WebLink AboutWell info � M/NNESOTA UNIQUE WELL �WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. 'County Name WELL AND BORING CONSTRUCTION RECORD g 1 g 0 2 4 Minnesota Statutes,Chapter 10.3I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED , ,, IS1 h 3-25-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven [I,Auger �Rotary � House Number,Sireet Name,City,and ZIP Code of Well Location ❑Other � 3�75 Facwiew Lane, OCQL�Q 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �,��r From ft.To ft. � Showing property lines, ro ds,buildings,and direction. USE N e"' � , �Domestic ❑Monitoring ❑Heating/Cooling , , , , � �� s�'.J,• "" Environ.Bore Hole Industr/Commercial __;__ �___ _ �_ __,_ ❑Noncommunity PWS [� ❑ Y �� ❑Community PWS ❑Irrigation ❑Remedial �' ' ' ' ___;_ � �Elevator ❑Dewatering ❑ �; w � ; ; ; e CASWG MATERIAL Drive Shoe? ❑Yes �'No HOLE DIAM. --�--- --�--—�-----*-- /M�` �J Steel ❑Threaded ❑Welded s ❑ '� lastic 1 --�----�- --�-- --� � � -- „�,�---+...�,� CASING ' ' S ' � � ) Diameter Weight Specifications �—�Mile—� � in.To 1�ft. Ibs./ft. in.To_�_ft. PROPERTY OWNER'S NAMEiCOMPANY NAME in.To ft. Ibs./ft. � in.Tol JL R. ; asbe Stofferahn in.To ft. Ibs./ft. in.To n. OPEN HOLE ; Property owner's mailing address if different than well location address indicated above. SCREEN � Make �� From ft. To tt. Type 4td�T1�A+�$ $t�� Diam. SIoVGauze �� Length � ��t Set between ft.and ft. FITTING STATIC WATER LEVEL Measured from :i � ft.�Below ❑Above land surface Date measured " � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1 I3� ft.after 2 hrs.pumping 50 g.p.m. ' Well/boring owner's mailing address if diflerent than propert er' d e r ted above. WELLHEAD COMPLETION .� � �Pitless/adapter manufacturer �t��$t�r Model � ❑Casing protection „[5�12 in.above grade CITY OF ORONO �At-grade ❑Well House [,i Hand Pump - GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material�@(I�fn't�tP_ From�_To��_ft. __�_ ❑Yds. �'Bags Matenal ttll Cfl1Si� �r�r��To�f�_ft. �Yds. �Bags HARDNESS OF Matenal From To ft. ❑Yds. []Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION t��$�j l black 8�f t � 2 �>y} feet -..:: direction �_type Well disinfected upon completion? es [�No � �SyI�',L'fiV'E.'1 �.?CdWII I�IEq Z �I PUMP ; ,t 1 t/� []Not installed Date installed .T![J�� ay �ra�7 �1�) �i 11J7 Manufacturer's name �j�'��r y _ - [DU�gravel �}J.�i 171G�11i� if1'7 �� Model Number HP �1�� Volts �� tJ! Length of drop pipe � ft. Capacity g.p.m 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 � 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 Stodo2a 4�Te11 Ikillin�; Co,.Inc. 1691 Licensee Business Name Lic.or Reg.No. , � ___� :�,-, 4 5-16 .�,'l f,•�� f, .. _ !.� "� ,. q. Representaiive Sig�ature Cerlified Rep.No. Date LOCAL COPY g 18 O 2 4 Name of Driller ��v .7t�OI� . ID#52603 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: 16-02837 Twin City Water Clinic Inc. Sample Collection Date: 03/15/16 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 8:00 Hopkins, MN 55343 st.sonifacius,MN 55375 Sample Receipt Date: 03/16/16 Phone: (952)935-3556 Report Issue Date: 03/18/16 Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 16-02837 Coliform Drinking Water 03/16/16 13:16 Absent 16-02837 Nitrate/N Drinking Water 03/16/16 12:07 <1.0 mg/L 16-02837 Arsenic Drinking Water 03/16/16 8:00 03/18/16 11:55 2.82 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water Well No.: 818024 � X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: WeII si laboratory. [Laboratory name;address;MDH Lab ID#�. The Well Adr: 3075 Farview Lane;Orono,MN '�J� " � `��!�' subcontracted laboratory maintains MDH Certification forthe OWner: Gabe Stofferahn field(s)of testing performed. ('iITY OF ORO � Owner Adr: Sample Conditions: Sample Temp: 8°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,2.0µg/I,Lead,2.0 µg/L ' Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L - ^ .yt � /;? ./� 5� '�V i'l f/�� <f.�r1.�.�.C.�+�C.�rc_IGt�I.. Sample Collected by: X Client _TCWC Approved By: 2�;;- 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. TCW D Rev 2.0 Page 1 of 1 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �''i 1 �ounty Nam� WELL AND BORING SEALING RECORD M nneso a�Unique Well No. � r �'` ��erme�ir. Minnesota Statutes,Chapter 1031 or W-series No. (Leava Wank ii no�known) T i��{� Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construct�i�� fl 7 7 O�� r�rac� 117 2'� t�L� cc.a ewr �a � f �� u i � GPS LOCATION—decimal degrees(to four decimal places) �r ' C�-�y p��RONO Depth Betore Sealing /�� ft. Original Depth Latitude Longitude UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �n�/ *+ r WELUBORING Measured ❑Estimated Date MeasuredS�ml �N7I 3�?75 �arvi��r T.�n�, �c�nn �5356 �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 �J ft. �below ❑above land surface lines,roads,and buildings. N CASING TVPE(S) I � I ; _..__.___....._. --'---—y---_`_---''- .;�1' k � �teel [�Plastic ❑Tile ❑Other --'-----'------`-----'— i ,. i �" WELLHEAD COMPLETION W : ; : ; ET , e __�_____�_____�_____r__ �`�„_ Outside: �Well House ❑At Grade Inside: ❑Basement Offset , , , ; �Miie eess A p r/Unit ❑Buried ❑Well Pit , , , , �Pit da te --�--- --T—---%-----�-- , � , , ❑Buried � � S ' ' �� ❑W IIP't �•�,�t'��`"" ❑Other �1 Mile—� _. ,.�.�-�`�'��"� ❑Other__ PEIOPERTY WNE ' NAME/COMPANY NAME CASING(S) �"c�� t��ra�'ln Diam t�' { Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diNerent ihan well location address indicated above ��n.ffom Q to/�Z R. ❑YBS �No ❑Yes NO ❑ ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE i / / r Well owner's mailing address if different than p�operty owner's address indicated above Screen from1�tof�Lt�ft. Open Hole from to ft. OBSTRUCTIONS �,/ ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �y No Obstruction � � Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. "�y� ` Type_ �, 1 t-- r� t—��[�Removed �lot PreseM ❑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 R. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes ` o TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) �}� � l � Grouting Material/�/l��i��1`�/from � to� � ft. yards � bags from to it. 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. t)on Sto�ala t�Tell I�riZlic�� Co., Inc. 1591 Licensee Business N e `, License or Registration No. ,, ,�� .-__. _ J � �d ""✓" ,. - �„�,j /..i � C� entaf e ignature,. Certified Rep.No. Date pz "'�r". .� ".� �' -....!:�.; ,q ti, "`,•`i: 1��.vR-�'.`. ��.=4'' `i' LOCAL COPY H =i ai�� Name ol Person Sealing Well or 8 ring HE-01434-14 ID#53159 . SnsR