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Home My WebLink AboutWell Sealing Record . yyELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/N�G NO. ELL County Name WELL AND BORING CONSTRUCTION RECORD g 18 0 2 8 �� i� Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 4 23 10 �f,T SE��SW �� 204 " 5-i 16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool �Driven r�Auger `Ec�Rotary House Number,Street Name,City,and ZIP Code of Well Location i�pt� f" /� R � 91 DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes - No `; �aater Show exact location of well/oring in section grid with"X" Sketch map of well/boring location. From ft.To ft. Showing property lines, ', ' . roads,butldtngs;'nd direction. USE rv , .� �Domestic ❑Monitoring ❑Heating/Cooling �. � � , � �- :,,_,- ;_.: -t ', .n ii.,. f-. ._,� :; ; _;___ __, __� __;__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial , _, ❑Community PWS ❑Irrigation �Remedial � --'-- --;-- ---`-- ---`-- Dewater �� 4 �Elevator ❑ ing .. W ; ; ; ; E CASING MATERIAL Drive Shae? �,]Yes �Q`=('No HOLE DIAM. � --'--- --`-- -""`-� ""-'-- T �� ❑Steel ❑Threaded ❑Welded � , , , , , 'Fe Mile , , , , I Plastic ❑ �.. ---------------�-- ---%- 1 ' CASING S � Diam/eter c Weight Specifications �t Miie� `t in.To ��j ft. Ibs./ft. in.To �Q ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. in.To— " tt. `�'(� �t��f� in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well locatio t SCREEN OPEN HOLE � Make�� From ft. To ft. SEP G 6 7.01F TYPe�C�I��I.CC� G� SIoUGauze_ Length Set between � fl.and ft. FITTINGS �j'TM OF ORONO STATIC WATE L Measured from � ft. Below ❑Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surtace) 2� ft.after � hrs.pumping �� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer t��h��r Model ❑Casing protection �12 in.above grade ' ❑At-grade [j Well House ❑Hand Pump 7 GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) ; t,,� � Material ��l��tF�rom � To n5� ft. � ❑Yds. �Bags Material�tu�1g� L�� SQ To �75 ft. �Yds. ❑Bags HARDNESS OF Matenal From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION to,�soil black ft 0 2 � _� -_ �- - ' __feet __ �-- direction --— ' s-�'�y �� Well disinfected upon completion? Yes ❑No -� "� Y ,_� - � � = CZHy �C{yi0C1 �.tl�l 2 Z� PUMP _ _ [j Not installed Date installed r1�7��Ei clsy gray ft 2Q 139 Manufacturer's name ��Y ��V b�,�� 1� ��y �p� Model Number HP 1�5 Volts � � � O Length of drop pipe � ft. Capacity g.p.m - ��Cl�y �ray .i� 1i72 ln� Type:� Submersibie ❑LS.Turbine ❑Reciprocating �Jet ❑ ABA DONED WELLS �ravellsand 1Tl�X i,j]j!] 173 ZtFt Does property have any not in use and not sealed well(s)? I�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 i1 needed. REMARKS,ELEVATION,SOURCE OF DATA,eta � �'t(�O�S Well Drilifng Co,. i�• 1fi9I Licensee Business Name Lic.or Reg.No. . .�"'� � ��1� _/•" �' if' R r seni ive ' Certified Rep.No. Date , _ LOCAL COPY 81 H O 2� Name of Driller �� tO�.a18. ID#52603 HE01205-15(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 Cli2nt: Don Stodola Well Drilling Report Number: 16-07063 Twin City Water Clinic Inc. Sample Collection Date: 05/19/16 617 13th Avenue South ACICII'ESS: 3841 North Main Street Sample Collection Time: 16:0o Hopkins, MN 55343 st.sonifacius,MN 55375 Sample Receipt Date: o5/zo/15 Phone: (952)935-3556 Report Issue Date: o5/z3/16 Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 16-07063 Coliform Drinking Water 05/20/16 13:01 Absent 16-07063 Nitrate/N Drinking Water 05/20/16 13:17 <1.0 mg/L 16-07063 Arsenic Drinking Water 05/20/16 8:00 05/23/16 10:57 21.30 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg�L Drinking Water Drinking Water Well No.: 818028 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: Well laboratory. [Laboratory name;address;MDH Lab ID#]. The Well Adr: 1449 Bay Ridge Road;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Tom Otteson field{s)of testing performed. OwnerAdr: 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,2A µg/L Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen, 1.0 mg/L Nitrite,1 mg/L ,r1 � - Sample Collected by: X Client _TCWC Approved By: t� � � `�'""��""w`'�'`'�`"`"'`` �{�f�f , ` BiIIVVan 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 2.0 Page 1 of 1 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � ��}�� ` WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. y ` p County Name ��p Minnesota Statutes,Cha ter 1031 or W-series No. nrze�i n P ��ea�e b�a�k��o�k�ow�� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �rono l 17 2� 1� �r+�x �d' �d � � GPS LOCATION—decimal degrees(to four decimal places) � Depth Before Sealing �� ft. Original Depth fl. Latitude Longitude A� IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ��f,�/� w , WELLiBORING - Measured ❑Estimated Date Measured .J/�/I tG /?�� . 14G� ?� ��{�e �'-� ��'rc�rrn 55391 ater-Supply Well ❑Monit.Well ( Show exac4 location of well or boring Sketch map of well or boring ti/l in section grid with"X" lopation,showing proper �Env.Bore Hole ❑Other ft. �below ❑above land surface ' I' s,roa ,and buil i N :V,j�-r�� i�� CASING TYPE(S) --'--- --'--- ---`—---'-- ._..,�._.�.��J Steel ❑Plastic ❑Tile ❑Other W _____ __ ___________ _' E _C� WELIHEAD COMPLETION ; � � : __�_____�______�_____r__ �u"�Y utside: ❑W II House ❑At Grade Inside: ❑Basement Offset T o e , , , , 'h Miie less A p r/Unit ❑Buried ❑Well Pit , , , � �Pit da te --.-----r---�-- ---:_ l : - ❑Buried S ❑Well Pit ❑Other F—1 Mile--� ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diame r�� i Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if differeM than well location address indicated above �� in.from � to ft. Yes �No � ❑ ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown RECEIVEDin.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE ., .., �•� ,r I � Well owner's mailing address it diflerent than property owner's a tlress dicate a ove Screen from !`74 to�ft. Open Hole from to ft. OBSTRUCTIONS CITY OF ORONO �Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obsiructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. 0 � TYPe— ❑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 Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed � in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE � Was a variance granted from the MDH for this well? ❑Yes o TN# GROUTING MATERIAL(S) (One bag ot cement=94 Ibs.,one bag oT bentonite=50 Ibs.) Grouting Material�✓�ry! ��%�from � ' to�ft yards �t7 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 �, Jo How many? g 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. non Strx�ola Well Drillint; Ca., Ir�c. 1<,'?l Licensee Business Name License or Registration No. __. �� ,,el �f i� � � - 1 �n �Nli fese tive,,S1g tur Certilied Rep.No. Date " 3 � �� '� r� LOCALCOPY � Name of Person Sealing Well or Boiing HE-01434-14 ID#53159 5/13R