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� MINNESOTA UNIQUE WELL
WELL OR BURING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name � WELL AND BORING RECORD � � � 5 �2
Minnesota Statutes,Chapter 103/ �
Township Name Township No. Range No. Section No. �' Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED
�
n.
GPS Latitude degrees minutes seconds DRILLING METHOD
LOCATION: --- r�CableTool [�Driven ,Dug
Lon itude de rees minutes seconds � �
- 9 — 9 ` !Auger �Rotary _�.Jetted
House Number,Sheet Name,City,and Zip Code of Well Location or Fire Number '�
DRILLWG FLUID WELL HYDROFRACTURED? �]Yes f,�No
Show exact location of well/boring in section rid with"X` Sketch map of well/boring lo tion. �t��te From_ ft.To __ft.
Showing property ines.
N roads,buildings,and dir tion. USE �Domestic �_ ,Monitoring `_'Heating/Cooling
I ; ' �
,_ � _� , �(,J [J Noncommunity PWS , �.Environ.Bore Hole [�Industry/Commercial
��� '�' :.�/',�,� ��_ -,� !.�Community PWS , .Irrigation I�Remedial
: � �
__ __ __ __-- � ']Elevator �� ,Dewatering !1
� w ; ; ; .L e A��" CASWG MATERIAL Drive Shoe? ; �Yes �f No HOLE DIAM.
- -----,--- --�-----:- T - �S
- - �� ,...� , . teel I�Threaded ��Welded
�i --�--- --�--- ---�-----�-- ile
,/z M ; _
1 l � ,�Plastic I i
�i,-_ CASING
S ' . Diameter Weight Specitications
�---1 Mile—� � in.to i� fl. Z Ibs./ft �in.to�.ft.
� �p
PROPERTY OWNER'S NAME/COMPANY NAME in.to _ _ft. IbsJft. �in.t�._�V ft.
����� �� � in.to _ _ _ft. IbsJft. in.to tt.
OPEN HOLE
Property owner's mailing address if differeM than well loca�ion address indicated above. SCREE T.
1.�/��� �',�� A� 7'� Make •+�� . � __ . __ From ft. To ft.
� ���ll� M4�T 554�i7 TYPe a�afnless $t� . Diam.__.. ..
� SIoUGauze _ �� __. Length��,�.�1
��u'^� Set between_ _ _ft.and ft. FITTWGS_
f
� STATIC WATER LEVEL Measured trom t *
���%•�- � � +`�"�'� ft.'�{�3elow �_�Above land surface Date measured �l� iZ
� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
_ ��` ft.after �_ hrs.pumping Jl g.p.m.
Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION �{
; f�j Pitless/adapter manufacturer_�'++te�ater Model
,�Casing Protection _ __ __ � __ �12 in.above grade
� ��.At-grade(Environmental Well and Boring ONLY)
� GROUTING INFORMATION
� Wel���� 'N° � � � �
� Gro�ry� erial�Rli�N@eJr�qen�Bentonit�oncrete Other
i!S C 1 Lili
� From To ft L,Yds , _�Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft L.i Yds. i Bags
MATERIAL From To ft. f_]Yds. i. I Bags
. NEAREST KNOWN SOURCE OF CONTAMINATION
� �'�' -� feet '+� _direction �.i�.., -+-�C..+ type
Well disinfected upon completion? '',�Yes � ,No
PUMP
. r-�Not installed Date installed_ ___ 7�'L,Tl1
7 Manufacturer's name �er __
Model Number HP � Valts ��
Length of drop pipe ��� ft. Capacity �� g.p.m.
Type,:�Submersible L �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 tor this well? I,Yes No TN#
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chap�er 4725.
The information contained in this report is hue to the best of my knowledge.
Use a second sheet,if needed.
� REMARKS,ELEVATION,SOURCE OF DATA,etc.
�DOR2 ��OdQ�B �1� �.I�.��g CO.� �tlC. ���
Licensee Business Name . Lic.or Reg.No.
� _ J� '-ia�� �C7—��--
i
��r! *"
rtified Representative Signature �� Certified Rep.No. Date
.��9 �l�t�S
LOCAL COPY 7 8 3 5 0 2 - - ---- -
Name of Driller
HE-01205-12(Rev.i2/08)
IC 140-0020
� ♦ .1
Minnesota State Laboratory ID#027-053-119
Twin City Water Clinic Laboratory Test Report y�/�sconsin State Laboratory ID#105-10117
Cllellt: Don Stodola Well Drilling Co Report Number: iz-o�z Twin City Water Clinic Inc.
Sample Collection Date: oi/iz/iz 617 13th Avenue South
Address: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343
St.Bonifacius,MN 55375 Sample Receipt Date: oi/is/iz Phone: (952)935-3556
Report Issue Date: oi/i6/iz Fax: (952)935-5077
Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test
Sample ID Date Time Date Time Results Units
12-00528 Coliform Drinking Water 01/13/12 13:41 Absent
12-00528 Nitrate/N Drinking Water 01/13/12 13:20 <1.0 mg/I
12-00528 Arsenic Drinking Water 01/13/12 9:30 OS/16/12 10:40 4.72 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.: 783502
with'**'designation were produced by a subcontracted Sample pt:
laboratory.
[Laboratory name;address;MDH Lab ID#�. Well Adr: 3215 Graham Hill Rd.Orono,MN
The subcontracted laboratory Owner: Charles Cudd Denova
maintains MDH Certification for the field(s)of testing Owner Adr:
Sample Conditions:
Sample Temperature: 18 �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,
SM9222B- Coliform-<1 cfu/100 ml
Coliform, 1 cfu/100 ml
Nitrate Nitrogen 10.0 mg/I Wisconsin and EPA
SM4500D- Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.o µg/I guidelines for safe
Lead, 15.0µg/I drinking water for the
SM 3003-Arsenic, 2.0µg/I analytes tested.
, ,� ,� ,7
v^ � ' '�.u,�.���-(�
�,��i �- -
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