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Home My WebLink Aboutwell info �_ MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name __ _. WELL AND BORING RECORD � � 6 g J � Minnesota Statutes,Chapter 103/ € t nenr�ep�n Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Ot�o 117 23 04 N�� ?� SE�� I6� " '�-I-10 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds . __ Longitude degrees minutes seconds . �'Cable Tool ❑Driven Dug Auger ,�'Rotary ❑Jetted House Number,Street Name,City,and Zip Code ot Well Location or Fire Number � � G'ilJlJ FOX SL� blCOT�I 55391 DRILLING FLUID WELL HYDROFRACTURED? �]Yes ;�No Show exact location of well/boring in section grid with"X" Sketch.�nap of well/boring location. �� From ft.To ft. i /'y� Showing property lines, N f 'roads,buildings,and direction. USE �Domestic . �.Monitoring '_.]Heating/Cooling __;___ __y__ ___�__ ___;_ ` �� `,_,�Noncommunity PWS � i Environ.Bore Hole ��J Industry/Commercial � ` � �,]Community PWS ! �Irrigation j]Remedial __�_____;___ ___:__ __.__ t a -- �,Elevator ';Dewatering ❑ w ; ; ; ; E '—: "—`, CASING MATERIAL Drive Shoe? (�Yes �No HOLE DIAM. —�-----�-----�-----'— T� �'._:. :. >. ; ..`. .--Steel � .l Threaded ❑Welded , , , , 'h Mile j � � , , , , � ; I�`Plastic . --�--- --�-- ---%-- --�- �` + CASING ' ' S ' 1 t +- � Diameter Weight Specifications F---1 Mile--� �_in.to_�,.fj�ft. �_Q Ibs./ft. �� _�_in.to_ �t. PROPERTY OWNER'S NAME/COMPANY NAME in.to _ft. Ibs./ft. �in.to�.�[. �r�� in.to ft. Ibs./fl. in.to ft. OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 1�0� ^�� `� w Make s n �$� a From ft To ft. PiV�t�th i�tN 55b�49 Type i+iil_ L�ength 4' + 4' J=�•+ : SIoUGauze_ __ •- Set between_.�j$__ft.and�� ft. FITTINGS�„ ~ RECEIVEp STATIC WATER LEVEL Measured from_. __�� ft.,��Below � J Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME �O}O PUMPING LEVEL(below land surface) / �,�j� ft.after �S hrs.pumping g.p.m. Well!boring owner's mailing address if different than property g61p$i�,3 d above. WELLHEAD COMPLETION . vlT��Q �C Pitless/adapter manufacturer_ .� � '� �- '��>� - � �� "'�R+bdel �Casing Protection �12 in.above grade I� '�At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION /� / Well�iE�� .----NO �l. �� — `! � Grout a i l eat ceme �Bentoni oncrete �� ',Other ��ri;�� `�'� `�� - From _To ft. �=i Yds. ��.Bags HARDNESS OF From To ft �;Yds [�Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From To R ❑Yds. �Bags _ NEAREST KNOWN SOURCE OF CONTAMINATION CZS Q11Q� .�1 � __ ' i' { � _feet ' � direction - r . type " Well disinfected upon completion? �;'�Yes � �No CI8 .:�� "� PUMP []Not installed Date installed_ ' '-� � � � �� r�� Manufacturer's name Model Number ✓ HP�Volts .�'—�'..) ,�r��/��a ��. ��t Length of drop pipe � f ft. Capacity g.p.m. � �� r � Type: ' ubmersible �, f LS.Turbine �� '.Reciprocating ❑Jet j] Z 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? �_.J Yes No TNk WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. 7he information contained in this report is irue to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. �Q[i ,�j��Qla �ell Driiling Co�� 1�• Licensee Business Name Lic.or Reg.No. /� r J' �� ; � "� Certified Representative Sigttature CertiTied Rep.No. Date Vi{115:� 1�;,7V� LOCALCUPY 7 7 6 8 5 4 Name of Driller IC 140-0020 HE-01205-12(Rev.12/08) � Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 CIIEIIt: Don Stodola Well Drilling Co Report Number: io-ozlza Twin City Water Clinic Inc. Sample Collection Date: io/Za/io 617 13th Avenue South ACICII'e55: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: io/z9/io Phone: (952)935-3556 Report Issue Date: ii/oi/io Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 10-10178 Coliform Drinking Water 10/29/10 13:44 Absent 10-10178 Nitrate/N Drinking Water 10/29/10 14:26 <1.0 mg/I 10-10178 Arsenic Drinking Water 10/29/10 9:00 11/Ol/10 10:41 <2.0 µg/I Lead Drinking Water µg/I 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 subcontracted laboratory. Sample Location-#776854 [Laboratory name;address;MDH Lab IDN]. Charles Cudd 2400 Fox St.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, Coliform-<1 cfu/100 ml SM9222B-Coliform, 1 cfu/100 ml Wisconsin and EPA Nitrate Nitrogen 10.0 mg/I uidelines for safe SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.0 µg/I g SM 3003-Arsenic, 2.0µg/I �ead,15.0µg/I drinking water for the SM3113-Lead, 2.0 µg/I analytes tested. '✓'� .:>,;/ �.Cl�.e�.ul�lca��l Sample Collected by: X Client _TCWC Approved By: „ � `�� BiII 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 ��`*"„�]'�� - WELL AND BORING SEALING RECORD M nnle90 aoUnique Well No. �� County Name x�--�p' Minnesota Statutes, Cha/�ter 103/ or W-series No. +�i.iN1Gp�� r (Leave Dlank�i�not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � ii� 23 cw sw n��' s� ia � iv , GPS Latitude__ _ degrees_____ minutes__ seconds Depth Before Sealing �� ft. Original Depth ft. LOCATION: Longitude degrees minutes____ seconds UIPER(S) � STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer G ,-�t�l W LL/BORING 'Measured ❑Estimated Date Measured_.J I�'/�� Water-Supply Well ❑Monit.Well f Show exact location of well or boring Sketch map of well o oring S�+ in section grid with"X" location,showing pro rty ��Env.Bore Hole ❑Other ft. �below ❑above land surface lines,roads,and buil gs. N CASING TYPE(S) � --'--- --i-- ---'-----'-- �� Steel ❑Plastic ❑Tile ❑Other :'�� ; I I I �� ----- -- --- -------- -- WELLHEAD COMPLETION W : ; � ; ET '� � � _�____r__ � � Outside: ❑Well House U At Grade Inside: ❑Basement Offset " 'h Miie `t ❑Pitless Adapter/Unit �Buried ❑Well Pit - 1 ' �j `]Buried S ❑Well Pit ❑Other F--1 Mile—� �-- 1 ` ❑Other \..�� . . PROPERTY OWNER'S NAME/COMPANY N i CASING(S) - Diameter � Depth � Set in oversize hole? Annular space initially grouted? - Property owner s matling a ress rf di erent t an well lowtion address indicated above // � �in.from_�__ to�ft. ❑Yes [�Vo ❑Yes ❑No ❑Unknown 15050 23cd AV� N in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown P2ymaiih, � 55447 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � ' Well owner's mailing address if different than property owner's address indicated above SCreen from_C to�__ft. Open Hole ffom to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �]No Obstruction I Type of Obstructions(Describe) ��(J/J� / /�1��/Y� ��J GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑No Describe FORMATION If not k�own,indicate estimated formation log from nearby well or boring. PUMP . � . Type — ❑Removed —' ot 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.trom ro ft. ❑Perforated ❑Removed Type of Perforator � ❑Other _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � -�'' i � Grouting Material�,��!__�f'��C✓ffom�_ to� 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 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. Uon Stodols t�e21 nri.11in� Co,. Inc. I691 � Licensee Business Name License or Registration No. � ' .. / � r%•�J C p. s� �� ture � � " CertiliedRep.No. Date " 285708 �j� LOCAL COPY Name o/Person Sealing Well or Boring t HE-01434-11 IC#140-0423 � 2/OBR