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Home My WebLink AboutWell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � j �°� � �� WELL OR BORING LOCATION WELL AND BORING SEALING RECORD MinnlegoNa Unique Well No. 1 � `)�- Co�nry Name� � Minnesota Statutes,Cha ter 1031 or W-series No. P (Leave blank it no�kn wn1 TT� ca; Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed � , �� m�aN �2 / � GPS Latitude___ degrees minutes seconds Depth Before Sealing /�� R. Original Depth ft. LOCATION: �ongitude degrees minutes seconds hA�QrUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � �!'�1 Single Aquiter ❑Multiaquifer /�� 755 Fecn�al� R� �� tJ�fl� 553A1 1 W LUBORING �Measured L]Estimated Date Measured �� /'�" ,_]Water-Supply Well ❑MoniL Well � Show exact location ot well or boring Sketch map of well oc b rin - in section grid with"X" location,showing prope ty_ _J Env.Bore Hole ❑Other f�� _h. �below ❑above land surface N lines,roads,and tluildin�s. CASING TYPE(S) i �' __'___ __�__ ___`__ '_''__ ' � i { i Steel [;Plastic [;Tile [._�Other _ i -- - -- �y ! � WELLHEAD COMPLETION ` W ' ' ' E d II H G d I de t Off t :��. � � � � T • �' utsi e We ouse ❑At ra e nsi : i__!Basemen se � � � � --;--- --�--- --%--'--*-- � . � , . ; � � � � 'h nniie � � Pitless Adapter/Unit ❑Buried L J Well Pit . --,--- --,-- --.-----:- 1 ► [j Buried S ❑Well Pit ❑Other _______ - F--t Mile� . �_j OthBf PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Di�je� � Depth G � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above in.ffom �� I �] ��Unknown __ � to l�/ ft. �_,Yes �lo i__ Yes No in.trom ro ft. �]Yes (�Na ❑Yes [,No ❑Unknown _in.from to ft. I_]Yes L�No ❑Yes []No [j Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE , /� ,� ' Well owner's mailing address if diflerent than property owner's address indicated above Screen ffom �YJ� to �� ` ft. Open Hole from to ft. n t OBSTRUCTIONS Rods/Drop Pipe �, �Check Valve(s) ❑Debris ❑Fill ��No Obstruction Type of Obstructions(Describe)�/V/V�� T,� 9- /�� . GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe_ FORMA710N - PUMP If not known,indicate estimated formation log from nearby well or boring. t��Q ^ ..,i � /. � TYPe�.L',� {./[�/�---��- -�� ' � ` � '�� j�Removed ��Not Present ❑Other !� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑Annular Space Grouted with Tremie Plpe [j Casing Perforation/Removal in.from _ to ft. ❑Perforated �]Removed in.from_ to ft. ❑Perforated L�Removed a Type of Pertorator_____ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �+ � r Grouting Material�F�,/ ��,�/�-�/ from__�__ to_f?,�__ ft. yards �'� bags i from to tt. yards bags _____ from_ to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused wetl 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. M1 � Stc�ala t,iell Drilli � Co I . Licensee Business Na e License or Registration No. ��:/�"! ._. �� / /�� .- r' epresentative Signature � Certified Rep.No. Date H •- �,��.-. _:-r'_:�: %:r --- LOCAL COPV 313 2 31 Name ol Person Sealing Well or Boring� HE-01434-13 IC#140-0423 5i72R _ _ __ . , .. , _ _ __ �._� �-,— .�___ � �! MINNESOTA UNIQUE WELL ` V�E'L�OF31NG LOCATION MINNESOTA DEPARTMENT OP HEALTH AND BORING NO. ' ca��Y N�,nP WELL AND BORLNG RECORD 7 g 2 0 2 0 � Minnesota Statutes,Chapter f037 Township Name Township No. Range No. Section No. Fraction WELIJBORING DEPTH(completed) DATE WORK COMPLETED �COI'1�� Z.�S � �! � ■`i+y� �+�a �� n' �16—I3 GPS DRILLING METHOD - Latitude degrees minutes seconds LOCATION: -- - ❑CableTool f]Driven Longitude degrees minutes ___ _ seconds []Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other !)S �G[1t�C � if t)s�a�o► 553�31 DRILLING FLUID WELL HYDROFRACTURED? C Yes o Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. '�t��tC From ft.To ft. Showing property lines, - N roads,buildings,and direction. USE 1/Domestic ❑Monitoring ❑Heating/Cooling y`i �`: __;___ __�__ __;____;__ �� '�]Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial e --'--- —;--- --`-----�-- [�Elevator ❑Dewatering ❑ ��':. �� w ; ; ; ; E CASING MATERIAL Drive Shoe? �Yes ❑No HOLE DIAM. .,; --�-----�--- --F-----%-- -�" T �Steel fxThreaded [�Welded ± ; , ; , Mile j Plastic ___ _ / C�'� � ' --;-----�------%-- --�- I � 1 �Q/� CASWG S � Diameter Weight Specifications �—�nniie� ;�.,n .�,.JLR...�.q„ � � .__�_in.To Z��ft. Ibs./ft. �in.To_�ft . PROPERTY OWNER'S NAME/COMPANY NAME - � - � in.To____ ft. _ Ibs./ft. �__in.To2��fl J� � ��y„� in.To ft. Ibs./ft. �$�.To�_ft ��5� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN Make From�_ ft. To ZDV ft. Type Diam._____ SIoUGauze Lengih Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from �,�{3 ft. Below r 1 Above land surface Date measured_.�._��+ WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ` � ft.after v hrs.pumping � _�.p.m. Well/boring owner's mailing address if ditterent than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacture��te�t� __ Model - �Casing protection ____ �2 in.above grade ❑At-grade ❑Well House [�Hand Pump GROUTING WFORMATION(specify bentonite,cement-sand,neaPcement,concrete,cuttings,or other) Material��rom_�To__�ft. _ �_�_� '�_;Yds. �ags _ Matenal�!_�1�To AM_ft _ ___ []Yds. �]Bags Z 1 --ZTL - HARDNESS OF Matenal From To ft ❑Yds. []Bags �? --------- -- ----�-- .. GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From_ To___ _Bags NEAREST KNOWN SOURCE OF CONTAMINATION �� fliV�3 �Q�t 0 ,7E7 /CG� feet 1-�-� direction��' type � Well disinfected upon completion? j�Yes ❑No L7Li�i7 lOC7C.Li.� .3V SZ PUMP �_;Notinstalled Dateinstalled __,______�1,.�-i,3__._ � C� �y,� �� +�� Manufacturer'sname_.7L12�Cler ______. _ �1u�e� ModelNumber HP ��! Volts 6.7V bOtilt�[ �BCC� �.2 1�.3 ---- Length of drop pipe �� ft. Capacity g.p.m .._�1/ �� i� �t� 11 9 t�1 Type:� . ubmersible ��_I LS.Turbine ❑Reciprocating ❑Jet ❑ �1� L i i.7 1 1 ABANDONED WELLS �u} �� j� �� e�� Does property have any not in use and not sealed well(s)? ❑Yes No �i1i�l 1 '� VARIANCE �� q� 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. I � �� ZY� 2g1 The information contained in this report is hue to the best of my knowledge. �lC Use a secon t.if needed � � REMARKS,ELEVATION,SOURCE OF L��t�e/ ��'i�n Stodoia t�ZI �rilling Go�� 1�• 1�91 �� 8�Y -------- -------- —___ --- - ��`� �� `�� Licensee Business Name Lic.or Reg.No. / _ � �_. .-' 7-22-13 r�� d resentative Sign2ture � Certified Rep.No. Date � 792020 �' ��'� LOCAL COPY - --- ---- Name of Driller IC 140-0020 HE-01205-13(flev.11/10) . ,. - Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 CIte11t: Don Stodola Well Drilling Co Report Number: 13-52�5 Twin City Water Clinic Inc. Sample Collection Date: os/ie/is 617 13th Avenue South Address: 3841 North Main Street Sample Coll�ction Time: i3:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sarnple Receipt Date: os/i�/i3 Phone: (952)935-3556 Report,lssue Date: os/zo/i3 Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 13-6275 Coliform Drinking Water 05/17/13 13:22 Absent 13-6275 Nitrate/N Drinking Water 05/17/13 13:20 <S.0 mg/I 13-6275 Arsenic Drinking Water 05/17/13 10:30 05/20/13 11:19 <2.0 µg/I Lead Drinking Water µg/� Drinking Water �rinking ilvaier Drinking Water Well No.: 792020 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: 755 Ferndale Rd N;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 8 °C Discussion: Notes: ' Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: SM92Z26-Coliform, 1 cfu/100 ml Coliform-<1 cfu/100 ml, Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen, 1.0 mg/I qrsenic,10.0 µg/I SM3113B-Arsenic, 2.0µg/I Lead,15.0µg/I SM31136-Lead,2.0µg/I � r )t�1�� ; '1/?,,,'j �:� .. Sample Collected by: X Client _TCWC Approved By: � ' '"L' 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