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Home My WebLink Aboutwell info ' MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORWG NO. � County Name WELL AND BORING RECORD 7 8 8 2 3 5 Minnesota Statutes,Chapter 1031 Township N e Township No. Range No. Section No. Fraction WELL'BORING DEPTH(completed) DATE WORK COMPLETED �cono II7 23 03 S� Ng S�i,, Ib3 h ].2—i4-2011 GPS DRILLING METHOD ' LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds U Cable Tool Driven � ❑Auger �Rotary House Number,Sheet Name,City,and ZIP Code of Well Location Fire Number ❑Other Gi� FC� St� iJLS7llf! S�JI[J DRILLING FLUID . ��ELL HYDROFRACTURED? C Yes No Show exact location of well/boring in section grid wit " Sketch map of well/boring location. W$�e(� From ft.To ft. Showing property lines, � N roads,buildings,and direction. USE �Domestic _Monitoring ❑Heating/Cooling 4 � __J_.__1____l_. __L_ . �,'.� �Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �� . ;Community PWS ❑Irrigation ❑Remedial � � � � --�-----;------�-- --_-- . ,Elevator ❑Dewatering - w , ; ; E T CASING MATERIAL Drive Shoe7 ❑Yes ,�r�No HOLE DIAM. , --- - I ��, „ [J Steel` ❑Threaded ❑WeldEd 'h Miie . �Plastic � ❑ --�--- --T-- ---�----�-- CASING S � iameter Weight Specifications ��Mile-� ��' `,"� 9 in.To�� n. 11 Ibs./R 77L� To__�ft PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. ____Ibs./ft. �in.To��ft VCf7r e �7�7CC:� in.To ft. Ibs./ft. in.To ft � OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN _ Make �� From ft. To ft. Type StRf411.�$$ St�►1 Diam. � SIoUGauze �'��Lengt��'*�� j'� Set between� ft.and i'�� ft. FITTINGS i�� ie STATIC WATER LEVEL Measured from�-q��J��'�� 7� ft.�Below ]Above land surface Date measured i¢�1'* �+ � WELL OWNER'S NAME/COMPANY NAME PUNI�I�LEVEL(below land surface) � y! t 7F.) ��7 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�ts� Model ❑Casing protection __ __ �72 in.above grade i ❑At-grade ❑Well House ❑Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neabcement,concrete,cuttings,or other) Matenal tlCiltVlil�eFrom�To�ft � [J Yds. ,�ags Matenal��$�,___ft£oj,i��To��_ft. [�Yds. ❑Bags HARDNESS OF Matenal From _To ft. U Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATEFIAL FROM TO Drivencasingseal From ___To Bags NEAREST KNOWN SOURCE OF CONTAMINATION C��x br�'W� �i� 0 � �� feet � __direction ��t��__type .�/� t� Well disinfected upon completion? Yes ❑Na ta9e1 b�j �� Jl/ VlJ PUMP I,]Not installed Date�in+s�ta�lle�d_�____��_a" �� U�� ""' Manufacturer's name `�'��C�et � � ��1 rs�� C8 �� t Q� Model Number�. HP } Volts 1 r� Length of drop pipe ft. Capacity g.p.m �� /�� t� ��=l� �nC �c� Type:�Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ V NlClil WJ � qgANDONED WELLS �[iCI (8 �1� �l't I63 Does property have any not in use and not sealed well(s)? ❑Yes �No VARIANCE Was a variance granted from the MDH for[his 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 lrue to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. D� Stvdola Wel2 Drillin� Co,. inc. 1692 Licensee Business Na Lic.or Reg.No. ' / 12 G7��1 ti e resentative S' a[ Certified Rep.No. Date Mark Stoclola �.�r��`�� 7 8 8 2 3 5 -- - - Name of Driller IC 140-0020 HE-01205-13(Rev.11/10) � 3 Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 CIIE?Ilt: Don Stodola Well Drilling Co Report Number: ii-o236s Twin City Water Clinic Inc. Sample Collection Date: iz/ia/ii 617 13th Avenue South A[ICICESS: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: iz/is/ii Phone: (952)935-3556 Report Issue Date: iz/i5/ii Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 11-12193 Coliform Drinking Water 12/15/11 11:56 Absent 11-12193 Nitrate/N Drinking Water 12/15/11 11:40 <1.0 mg/I 11-12193 Arsenic Drinking Water 12/15/11 9:00 12/16/11 10:40 3.16 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water X No samples were subcontracted;or the above test result(s) Well No.: 788Z35 with'**'designation were produced by a subcontracted Sample pt: laboratory. Well Adr: 2180 Fox St Orono,MN [Laboratory name;address;MDH Lab ID#]. The subcontracted laboratory Owner: George Ebbecke maintains MDH Certification for the field(s)of testing Owner Adr: Sample Conditions: SampleTemperature: 9 °C 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, SM92226- Coliform-<1 cfu/100 ml Wisconsin and EPA Coliform, 1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I Arsenic, 10.0 µg/I guidelines for safe SM4500D-Nitrate Nitrogen, 1.0 mg/I drinking water for the SM 3003-Arsenic, 2.0 I �ead, 15.oµg/I µg� analytes tested. L; :'.. ' � ', _ �r.�t�:�,�'�.�z�.�' 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 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �O��C Q ��;y Nar� WELL AND BORING SEALING RECORD M nnle90 a�Unique Well No. 5�� i� Minnesota Statutes, Cha ter 1031 or W-series No. P �e:,�e ma�k n�o�a�owm Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed pra�o Il 23 3 SS N� SW 2U ��C ♦ , GPS Latitude degrees___ minutes seconds Depth Before Sealing �f V fl. Original Depth ft. - LOCATION: Longitude degrees_ _ minutes seconds pUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and Ciry of Well or 8oring Location ' .,Single Aquifer ❑Multiaquifer �,M [� 21(?iJ �Qx Jt� erono 55356 �y/BOSupply Well ❑Monit.Well -Measured ❑Estimated Date Measured_J�/'Ml�� /9r Show exact location of well or boring Sketch map of well or boring � r�� in section grid with"X." location.showing property ��Em�.Bore Hole [�Other _ IL.3_._ft. �beiow ❑above land surface tN lines,roads,and buildings.\, CASING TYPE(S) :__ � . l-- �(y ; 1 � I _T �Steel ��Plastic ❑Tile ❑Other �T -----_ __ ---------- - ' --�-----�------�-- "-'�-- WELLHEAD COMPLETION , W � � , � E T __;____:__ __;___�_ I Outside: []Well House ❑At Grade Inside: �Basement OBset ffi � ' , , , M�'ie itless A p r/Unit ❑Buried [�Well Pit � ❑P� da te '; --�----T-- ---�-----�- I r',Buried ' ' 1 ❑Well Pit � ' S �-1 Mile� `!'�. ❑Other ❑Othef aa.J� PR�O+,P�E,�RTY OWNE NAM COMP NAME CASING(S) ' �1C �� Diameter , Depth r Set in oversize hole? Annular space initially grouted? � P�operry owner's mailino address if different than well location address indicated above �� in.fram�_.___ to_��ft. ❑Yes �No '�Yes ❑No ❑Unknown � ____in.from to_ _ ____ft [i Yes [�No ❑Yes ❑No ❑Unknown in.from ro ft. ❑Yes ❑No ❑Yes ❑Na r�Unknown 5 WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE . /� � Well owner's mailing address if diNerent than property owner's address indicated above SCr2en from��to ��V ft. Open Hole from _____to_. ft. e OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill y�Jo Obstruction „ Type of Obstructions(Describe)_ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions remaved? ❑Yes ❑No Describe � FORMATION If no[known,indicate estimated formation log from nearby well or boring. PUMP �,J� CJ /1� TYPe � I 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 ❑Other ___ GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) /1 /+ . r Grouting Material/Vi�/7'TC_��-�'from� t�� ft. _,_ yards� 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 borinr�on property? r�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. Uon Stodola WeI2 Drillin� Co., I�. 2fi91 ______ - - - ---- Licensee Business ame License or Regishation No. �' " �?/ it /� rtil epresen ative Signa r Certified Rep.No. Date _ LOCAL COPY H �O 1 Z S V `\ ""'��~��j Name of Person Sealing Well or Bo � � HE-01434-12 IC#140-0423 � j - g�agp J i