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Home My WebLink Aboutwell info ' � � � 274449 ' WELL OR BORING LOCATION MINNESOIh DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � County Name WELL AND BORING SEALING RECORD Menn'e90 a�Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. (Leava blank'ii no�known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ��/ Nor� o , _ GPS Latitude _ _ degrees___ minutes___, _ seconds Depth Before Sealing �7�� ft. Original Depth ft. LOCATION: Longitude_ degrees_ _ minutes seconds ---�--- A U ER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and City of Well or Boring Location r' �ngle Aquifer ❑Multiaquifer ��/ 1t�r�f 515 Fecndsle Rd N �F�� 55391 �W�L/�/BORING I�1M4easured ❑Estimated Date Measured �/-'/"� ��,_yNater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or bo ing J in section grid with"X." location,showing prope L�Env.Bore Hole ❑Other �� i ft. �elow []above land surface N lines,roads,and buildin CASING TYPE(S) ` --'--- --'------`----'-- I I�eel �� ❑Plastic ❑Tile ❑Other •�� --'--- --'--- --`- --- -- ELLHEAD COMPLETION _ : W : ; : : ET .,a - ,� W 'I __:___ __�___ __�__ __;__ ��Outside ell House , At Grade Inside: ❑Basement Offset : ❑W ��f � � , , , Miie �� ss A pter/Unit I_�Buried ❑Well Pit �f �tle da --.----,--- ---�-- ---:- 1 , S ❑Well Pit ❑Buried ❑Other �7 Mile� \� ❑Other J PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � � Oiamet � Depth � Set in oversize hule? Annular space initially grouted? Property owner's mailing address if different Ihan well location address indicated above ��n.from � to � �/ft. ❑Yes �Vo [�Yes ❑No ❑Unknown 1$283 Mirmetonka B2ar1, St� B in from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Iaeeghav�en,l�i 55391 in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , � Well owner's mailing adtlress if diflerent than property owner's address indicated above SCfeen ffOm�to /�� ft. Open Hole from to_ _ft. OBSTRUCTIONS - �ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) ��//�'�/` /"Tl''� p �)__�'j� GEOLOGICAL MATERIAL COLOR HaaDNEss oR FROM TO Obstructions removed7 es ❑No Describe FORMATION _ If not k own,indicate estimated formation log from nearby well or boring. PUMP � Type— J V�� r�U M�.� � � :�Zemoved �Not Pres nt ❑Other_ _ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: !,�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. [j Perforated ❑Removed s :f in.from to ft [j Perforated ❑Removed Type of Perforator _ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of be�tonite=50 Ibs.) ��,� /yy/� I Grouting Material r--• "" ��„�-'—from_ 0 to ,7�ft.____ yards /� bags from ro 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 o How many? LICEN5E0 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 ot my knowledge. - Don Stodo2� �Jell bri2ling Cs�,. Inc. I692 _ — _-- -- - , Licensee Business Name License or Registration No. . , / / � � C r * _�- _ _.=- __ / y � j C i� esentative Signature `=' Certilied Rep.No. Date �� M1 . u �I , �� LOCAL COPY i n 2 7 4 4 4 9 I� Name ol Person Sealing Well or Boring -----_-- _ ---_ _-_ . HE-01434-11 IC#140-0423 vosa � WELL CR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MI N AEND BORINI�G NO. ELL County Name WELL AND BORING RECORD (� �/ �� i� Minnesota Statutes,Chapter 103/ � �r �✓ � ` 0 Township Name Township No. Range No. Section No. Fraction WELUBORING?EPTH(completed) DATE W�ORK*CLOM��TED �r000 II8 23 36 i�1E Sl� NE�� G�iS „ C.�LCT GPS DRILLING METHOD Lati[ude degrees minutes seconds LOCATION: _�Cable Tool �]Driven �,Dug Longitude degrees minutes seconds �_��quger �Rotary �_�,Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number j, �� 515 Fer�ale 7W � ilLVISVSJ..77� DRILLING FLUID WELL HYDROFRACTURED? �.J Yes j�No Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo-ati . �j'}t�it� From R.To ft. Showing propert lin , N roads,buildings,and dir ctio�. USE h]I Domestic ❑Monitoring ❑Heating/Cooling � � , � �';..-� �� ,J Noncommunity PWS L i Environ.Bore Hole ❑Industry/Commercial — -- - - - --- — ! �..__._r. � - � �Community PWS L I Irrigation !]Remedial � � ' - -�-- -'h- ' �.-,� ,J Elevator L�Dewatering w ; ; ; ; e "� �Yr � CASING MATERIAL Drive Shoe? �Yes i�No HOLE DIAM. - '--- --'----�'��-�-`- T �/� 4 -��r, �S eel �Threaded '_�Welded t '/Mile , f 'Plastic ❑ --�-----�-- ---�-- ---�- � � CASWG S � �' Diameter Weight Specifications �1 Mile--{ ��,� �in.to .�� ft. _�_�IbsJft _�in.to��f. y, 3'/� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _ _. _._Ibs./ft. �_,{yin.to_r.�.�p. �Sl� �ls�d111 �S �T1G♦ in.to n. ib5.in. 37 �to l�i�. Property owner's mailing address if different than well location address indicated above. p� SCREEN OPEN HOLE 1Q��°`�� ' � Make From Z�v ft. To �� ft. �? t�,T ype_ Diam.__ �t'�! �^''� �� Slot/Gauze Length Set between ft.and it. FITTINGS STATIC WATER LEVEL Measured from llg _ ft Below ;J Aboveland surface �Date measured�� WELL OWNER'S NAME/COMPANY NAME PUtv��LEVEL(below land surface) � �� L ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION I�Pitless/adapter manufacturer�rhite�ter Model � �Casing Protection �12 in.above grade � 1 At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION /� �/� } Wel�� Na tl Jil 'i � GrouLmater�als�R i Neel qeipent�Bento�p;Concrete ❑Other �t�.�.LiL 1 1211 7C7 V From To ft. ❑Yds. �_.�Bags HARDNESS OF From To fl. n Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO -- From To ft. ❑Yds. ❑Bags _ NEAREST KNOWN SOURCE OF CONTAMINATION 7� ___feet � direction ��tiC type Well disinfected upon completion? �,�Yes ❑No PUMP ��Not installed Date installed L�►""Y-1V r Manufacturer's name �t..�...0 Model Number �r��r HP �� Volts �� ' � Length of drop pipe �,y�l 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 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dc� Stodoia We12 I3r t1.ir�; Ca,. Zrrc. 1�I Licensee Busines Na e Lic.or Reg.No. _ �: q..20-10 if d Represen ative Signa `re Certified Rep.No. Date LOCALCOPY 7 7 6 g 7 O �k �� Name of Driller IC 140-0020 HE-01205-12(Rev.12/08) i � Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 Clll'11t: Don Stodola Well Drilling Co Report Number: io-o2i2a Twin City Water Clinic Inc. Sample Collection Date: io/zs/io 617 13th Avenue South ACIdC255: 3841 North Main Street Sample Collection Time: ia:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: io/z9/io Phone: (952)935-3556 Report Issue Date: 11/oi/io Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 10-10177 Coliform Drinking Ulater 10/29/10 13:43 Absent 10-10177 Nitrate/N Drinking Water 10/29/10 14:24 <1.0 mg/I 10-10177 Arsenic Drinking Water 10/29/10 9:00 11/O1/10 10:35 2.79 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 su6contracted laboratory. Sample Location-#776870 [Laboratory name;address;MDH Lab ID#i]. Denal:Custom Homes 515�erndale Rd N.Orono,MN The subcontracted laboratory maintains MDH Certification for the field(s)of testing performed. Sample Temperature: 4 °C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the samples This Sample meets the listed above have the following reporting levels: Maximum contaminant levels: State of Minnesota, SM9222B-Coliform, 1 cfu/100 ml Coliform-<1 cfu/100 ml Wisconsin and EPA Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.0 µg/I guidelines for safe SM 3003-Arsenic, 2.0µg/I Lead,15.0µg/I drinking water for the SM3113- Lead, 2.0µg/I analytes tested. ` � � � ,�,��,.�i 7 � ,, %� �1� 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