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Home My WebLink AboutWell Sealing Record MINNESOTA UNIQUE WELL WELL OR.BO�iING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Counfy Name WELL AND BORING CONSTRUCTION RECORD g 2 3 4 3� � Mipnesota Statutes,Chapter 103I i , Township Na Township No. Range No. Section No. Fraction WELUBORING DEPTH(compieted) DATE WORK COMPLETED £ , i�s n �a�o-�6 � GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD ' Latitude Longitude ❑Cable Tool ❑Driven , ❑Auger �otary ,. House Number,Street Name,Ciry,and ZIP Code of Well Location []Other .`�-r 122(1 �cacketts cV��t i��i��{�»5539I DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section gri X" Sketch map of well/boring location. t�.[tt��te From fl.To ft. Showing property lines, � roads,buildings,and direction. USE ' N �Domestic ❑Monitoring ❑Heating/Cooling __j_____j___ __�__ ___;__ �,,,� � ❑Noncommunity PWS �Environ.Bore Hole ❑Industry/Commercial � �y S ❑Community PWS []Irrigation ❑Remedial --�-----�------=-- ---=-- �,,� Elevato - Dewateri '] '�( ❑ � U �9 � w e ` �, - CASWG MATERIAL D r i v e S h o e? ❑Y e s �— o HOLE DIAM. � T � : --;--- --;-----�-----:-- � ❑Steel !]Threaded ❑Welded 'h nniie � lastic -' ------ ------ ---�-- ---:-- 1 � � C �AS�NG S � Diameter Weight Specifications �i Mi�e--{ �in.To 154 ft. Ibs./ft. $_in.To_��. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To I7(�. Fielch For�an in To ft. Ibs./ft in.To ft. Property owner's mailing address if different than well location address indicated above. L SCREEN OPEN HOLE fi()2b P31Is�ury Ave S Make Qlin�� From ft To ft. �1ir�nea lis MN 55419 TYPe stainless stee2 Diam. � � SIoVGauze �S Length �,t► f� Set between ft.and it. FITTINGS STATIC WATER LEVEL Measured from * 4� ft elow ❑Above land surface Date measured ��l WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) L 5� ft.after 2 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 Whit�water Model ❑Casing protection �'12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT WFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material tX(]�Q21�.t L From�To__��ft. _�_ ❑Yds. �Bags Material��'�llt.n.1.--�tCC'L---iiJ--To j rlji ft. �Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��112 `�ST� p��! $C}lt � 1� /.i „1 feet �� direction � 1--•�'-'�-"t� 1 Well disinfected upon completion? es ❑No Cl$yI S8t1� �;L'Aj�' f��L�it 2$ �iO PUMP / ❑Not installed Date installed Zl1-17-16 �189e1�C1$� �CS� I}l��1�11 `!`� �3 Manutacturer's name Schaefer Model Number HP i�� Volts �� s�ndy clay gray medium 63 13$ Length of drop pipe ft. Capacity g.p.m „u' y�� r,t �qp �?O Type:�Submersible �J LS.Turbine ❑Reciprocating �Jet ❑ 3f2llU u i .�a ! ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE Was a variance granted from the MDH for this well? ❑Yes o TN# WELL CONTFACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. - The information contained in this report is true ro the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. _ Don Staiola We21 T�c�illing Co,. Ic�. 1691 Licensee Business Name Lic.or Reg.No. c....--" �'� ' 32-21-16 ifi �p SeMa �Si u '�� Certified Rep.No. Date Rt>b Sttx101a .. � L�Ci/�L Ci�PY '� . . � V L��7 ��J� Name of Driller . �� ID#52603 HE-01205-15(Rev.8/13) ::ii 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 Client: Don Stodola Well Drilling Report Number: 16-14049 Twin City Water Clinic Inc. Sample Collection Date: 10/10/�5 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 11:30 Hopkins, MN 55343 st.sonifacius,MN 55375 Sample Receipt Date: 10/11/16 Phone: (952)935-3556 Report Issue Date: lo/12j16 Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 16-14049 Coliform Drinking Water 10/11/16 1323 Absent 16-14049 Nitrete/N Drinking Water 10/11/16 12:43 <1.0 mg/L 16-14049 Arsenic Drinking Water 10/11/16 8:30 10/12/16 11:27 Q.0 µg/L Lead Drinking Water µg/L Nicrite/N Drinking Water mg/L D�inking Water Drinking Water Well No.: 823433 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 IDfi!]. The Well Adr: 1220 8racketes Point Road;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Welch Forsman field�s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 15 °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 SM92228-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 SM31136-Arsenic,2.0µg/I,Lead,2.0 µg/L Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen, 1.0 mg/L Nitrite,1 mg/L ''V r,�,;?��'/� L�,.l-��_�.l.c,.3G��-f Sample Collected by: X Client _TCWC Approved By: 1; ��; - Bill Van Arsdale Alan Senechal Laboratory Manager SeniorAnalyst 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 WEIL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ��.� 7 4 4 County Name WELL AND BORING SEALING RECORD Mennlego a�Unique Well No. ?T��j�n Minnesota Statutes,Chapter 1031 °ed�Nse�ies No_ Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed bron� 117 ?3 11 "�' ','S., .,1, GPS LOCATION—decimal degrees(to tour decimal places) � Latitude Longitude Depth Before Sealing ��2 ft. Original Depth tt. A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 1�7n `7[`�C��rAt ts nr�int �C�� '�E !}Pl� �5�� W�EL'L"/BORING �Measured ❑Estimated Date Measured'�� ,��"� �yvvater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property �'Env.Bore Hole ❑Other_ 3�ft. �below ❑above land surface lines,roads,and buildings. N (��. CASING TYPE(S) 1 J Steel ❑Plastic ❑Tile ❑Other --'---—y-- --`-----t-- ��:J � WELLHEAD COMPLETION W : ; ; : ET �. , __�___ __�___ __�__ ___;__ -.,�, � Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset � ; ; � ; 'h nniie less A p r/Unit ❑Buried ❑Well Pit � `\ --- � �Pit da te --:--- --r-------- ---=-- 1 � o � � ❑Buried S ' ' ❑Well Pit ; �rniie� ❑Other ❑�1her PFOPERTY OWNER'S NAME/COMPANY NAME CASING(S) t-T + Diameter Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above �� __in.from�. to.��_ft. ❑Yes �No ❑Yes ❑No ❑Unknown bQ2E� Pills�bty AvP � in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown �tinnep�oli.s, t�+t 5544�..4�- _ ._ � �::�.� in.trom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME � � ` ' . ,.; � SCREEN/OPEN HOLE �-�,�,;�. ��, � � s 1 Well owner's mailing address if different than properry owner's address indicated above Screen frofi��__t0��_ft. Open Hole ffom to ft. �^°'-�� ' ' , � � � '_� � � OBSTRUCTIONS ',�-`.. . . � ., � ,,,��/// �Rods/Drop Pipe ❑Check Valve(s) (]Debris ❑Fill ❑No Obstruction ..r Type of Obstructions(Describe) �/�/��f�' g �� GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes []Na Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � Type � �r Removed ❑N Present ❑Other METHOD USEDTO 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 No TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) t r Grouting Material/�/�C�Q��I�LAfT•from�_ 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? U Yes o 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. �on Stcvlola We1lPrilling Co., Inc. 1fi91 Licensee Busine�s Name License or Registration No. _ ,� %,��_ �= //- /- l� � �. rHliptl.Aep esentat ve 3igAatur " Certified Rep.No. Date li `� � � � ��, ,�-f�.a.u-�- LOCAL COPY e}'�� y �� Name of Person Sealing Well or Boring '" HE-01434-14 ID#53159 ._ 5n3R