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Home My WebLink Aboutwell info r � MINNESOTA UNIQUE WELL WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. ` County Name WELL AND BORING RECORD . , `' i�� f i �;pni�..a in Minnesota Statutes,Chapter 1037 ^ �• �� p � :. _fr ,� �� Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED �Conc} 127 23 �5 �J "��,�h�'; ,� .� n. GPS DRILLING METHOD LOCATION: Latitude degrees minutes __ seconds Longitude degrees _ minutes seconds �,_,��Cable Tool ❑Driven [_]Auger �otary House Number,Street Name,City,and ZIP Code of Well Location ❑Other � �4�5 ;"�..Lr�•ii �.C3�� r�1'� 55355 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �,�No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. t?�t n[ From ft.To ft. Showing property lines, ; N roads buildir�qs,a�d direction. USE ` ' ` /:', , ; . . ;.A I�Domestic ❑Monitoring 1-J Heating/Cooling ; , 'T .�.... ' ._ _.__ ___ ___�_ _.__ ❑Noncommunity PWS ❑Environ.Bore Hole �]Industry/Commercial , � v "`-- "� � ❑Communiry PWS ❑Irrigation ❑Remedial --'-----,--- ---`-----'-- ❑Elevator ❑Dewatering ❑ � w , , , ; E 4' 4`� CASING MATERIAL Drive Shoe? ��Yes �lo HOLE DIAM. , , , T ,>,- . _�___�.__. ' ' � -` � �,]Steel ❑Threaded ❑Welded .. , , , , Mile '/ r �� --�-----�--- ---%- ' I� .�lastic U .. 1 CASING S � . ,��V . Diameter Weight Specifications �iMne� _� in.To __7`��7 ft. Ibs./ft. � in.To_ �)�At �`� 1 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft Ibs./ft. ('� in.To �s�t t.q j1�E,, i�� in.Ta ft. Ibs./ft. in.To n Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE q�� Make 0� ��n1 1 __ From_ ft. To ft. Type__.._ Stc'�.�.Lil�$!g $�i Diam. _ t SIoUGauze ��,� Length_�j.� + (}�� Set between ft.and ft. FITTINGS „ i a — � STATIC WATER LEVEL 1�n Measured from _ � _� ft.�Below �]Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ?� ft.after 3 hrs.pumping_ 2� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �t�ater PiUess/adapter manufacturer_____ Model ___ �,'Casing protection _____ s[�12 in.above grade ❑At-grade []Well House []Hand Pump GROUTWG MFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_ t7C[iCOTI�C�rom V To�ft. � ❑Yds. (x'Bags MaterialCli#t�_,�1 f�r��_SO To_��ft. ❑Yds. ❑Bags HARDNESS OF Matenal From To _ft. ❑Yds. I..�Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From_____To Bags NEAREST KNOWN SOURCE OF CONTAMINATION to�sail black soft � 2 , > � _feet __ direction � � `-- type .._ '^.' ; � y +� Well disinfected upon completion? es U No CIB� j/�1�.CX� ��Uifl 2 �.J PUMP t ❑Not installed Date installed � £3-13-14 sandy ctay �ray mecii3.�n 33 �J Manufacturer's name �C�� _ ��8�/��V�� C�� i� �� Model Number HP__1_Volts Z� f � 16� _ft. Capacity g.p.m Length of drop pipe �c'��cavel �'jy� (�Q(,�,�„j„�(� 1�}� ��(� Type:j�ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS �nCiy C i$� r� 1��.��) 1� I�7 Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE cY$C�1 t'C� 1��i� 1C)'7 21 C� 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA.etc. - ±�r.�n Stodola ��ell �illin�� Co . Iczc. 1Ei92 Licensee Business Name Lic.or Reg.No. �r r---' '`� r ��` 10�'7�11€ , ; . , ' . . � .. Certiffed Representative Signature Certified Rep.No. Date ROk� Stodola a�OCAL COPY ' ' � � -- �.> � - Name of Driller IC 740-0020 HE-01205-14(Rev.5/12) . � Twin City Water Clinic L�bbratory Test Report Minnesota State Laboratory ID#0�7-053-119. Wisconsin State Laboratory ID#105-10117 CIIeCIt: Don Stodola Well Drilling Co Report Number: ia-osz�3 Twin City Water Clinic Inc. Sample Collection Date: o�/so/ia 617 13th Avenue South ACICICe55: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: o�/ai/ia Phone: (952)935-3556 Report Issue Date: os/oi/ia Fax: (952)935-5077 ' Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 14-08273 Coliform Drinking Water 07/31/14 14:57 Absent 14-08273 Nitrate/N Drinking Water OS/Ol/14 11:17 <1.0 mg/I 14-08273 Arsenic Drinking Water 07/31/14 12:00 O8/O1/14 12:28 2.16 µg/I Lead Drinking Water µg/� �rinking Water Drinking Water Drinking Water Well No.: 804554 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: laboratory. [Laboratory name;address;MDH Lab ID#t].The Well Adr: 3445 High Lane;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Mike Baden field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 17 °C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Max�mum contaminant Ievels: SM92226-Coliform, 1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen, 1.0 mg/I qrsenic, 10.0 µg/I SM31136-Arsenic, 2.0µg/I Lead, 15.0µg/� SM31136-Lead, 2.0µg/I } :�2 /�� fF� �'.�.� .1 ' �`;'.f',��,�.t1r,,.LCer�l'� Sample Collected by: X Client _TCWC Approved By: � " �l'��'� � 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 a�surance 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 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring � � � � � WELL OR BORW� LOCATION Sealing No. H .J �� v,� +,' r�„� County Name �`' WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, Cha ter 103i or W-series No. Henrae� �n P ��a�P e�a��,�o,k�ow�, Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed Date Well or Boring Constructed �r�� 117 G3 li� «� *vm.a� �� I /r_ � ( GPS LOCATION-decimal degrees(to four decimal places) ' Depth Betore Sealing_.__�� ft. Original Dep[h ft ,. Latitude _ __,____ �ongitude __ - - --- AOUIFER(S) STATIC WATER LEVEL Numericai Sireet Address or Fire Number and City of Well or Boring Location . Singte Aquifer � J�Multiaquifer /�n � WELUBORING �easured ❑Estimated Date Measured,��/��}F V/'!r ' 3445 �'it;h Laisa� �rono 55356 f�jyater-Su � We�� - �,` ppy [j Monit.Well f, � F �� Show exact location of well or boring Sketch map of well or boring ��., ,�/ in section grid with"X:' location,showing property � �Env.Bore Hole n Other_ .. ft. �9 below �.]above land surface � lines,roads,�and b ildings. N �`,�'�. �ASINGTYPE(S) � -- --------- --- -- - -- � �! '��Steel �_ J Plastic ,�Tile �_]Other--- ' ' ` "'` ELLHEAD COMPLETION `N ; ; ; � E O"'1G W - �i � __;____;___ _ :_ ___�_ T Outside: �_�;Well House �,_j At Grade Inside: ��_'Basement Offset ; � _ 'k Mile �itless AdapteriUnit LJ Buried . ;Well Pit _ ; ; ; ; 1 �_� � -- --.-- --�--- --�-- ---:-- ; � � � _j Buried S ' ❑Well Pit [l Other_ �1 Mlle-� ❑Oth2f _ PROP.fE7R�TY OWNER'S NAME/COMPANY NAME CASING(S) ��1R� Baden Diame er � Depth ♦ Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different ihan well localion address indicated above �, �R ,> �_in.from V to1�pL_ft. '�,Yes ��IVo ❑Yes ❑No (J Unknown _in.from to ft _!Yes �,_;;No ['�,Yes ❑No ❑Unknown in.from to ft. ❑Yes ��:No j_'I Yes ❑No �]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � r � `' � Well owner's mailing address it ditferent than property owner's address indicaled above SCreen from�.!�_�_ _�o�Q__,�_ft. Open Hole ffom______ to .__fL � OBSTRUCTIONS � 1 Rods/Drop Pipe ❑Check Vaive(s) f_�Debris I Fill �TJo Obstruction �°� Type of Obstructions(Describe)___ � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes [!No Describe_ FORMATION PUMP If not 'nown,.indicate estimated formation log from nearby well or boring. ?- C.> IC...> TYPe-- - - --- .--- �` _�;Removed �Jot Present f]Other___ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �Jo Annular Space Exisis � _�Annular Space Grouted with Tremie Pipe �_I Casing Perforation/Removal in.from to ____.ft. j_i Perforated ,'.j Removed _in.from _ to__ ft. ❑Perforated �,. J Removed Type o�Perforator ,�. �----- - ----- VARIANCE Was a variance granted from the MDH for this well? _�Yes No TNtk GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) / � f Grouting Material�✓FR/ ��I��{�om � to��fl._ yards_ (� bags f _ ____ from _ to fl. 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? j li 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. L�on Stodola t�le1l Drillin� Co,. Inc. 1f�91 Licensee Business Nam {' - License or Registration No ..- r^ � _. _�_,_�;_..,;�';':;. ;,. �'_ � �- ,�r Co1`ti6C ffepreSentative Sgnalure " Certified Rep.No. Date : - S/ � . / � LOCAL COPY H �y �`�' ��V 9 9 .�'�-r�... l✓ "'"'—�Y�LSSY\� — � Name of Person Sealin Well or Borin i '� HE-01434-14 IC#140-0423 5n3R