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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �„I '� /� �'i �� County Name WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No. `� '�� `` Minnesota Statutes, Cha ter 1031 or W-series No. ��n P iea�a eia�k�i�o�k�ow�,� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Ornno 11� 23 3Q S'� NW gF .:;;1 �o :�� =: GPS LOCATION- decimal degrees(to four decimal places) Depth Before Sealing � �� fl. Original Depth ft. Latitude __.__ Longitude _ A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location � Single Aquifer � -'�Multiaquifer ) 1�N� iRUl� �$� iCiis Qr«� 5S35b �"�ELVBORWG �1 Measured [ ]Estimated Date Measured ,Jti__�_ ��J I�Water-Supply Well j�Monit.Well Show exact location of well or boring Sketch map of well or boring L� in section grid with"X" location,showing property '�� '�Env.Bore Hole ❑Other____.__ ft ,-�.below ,- ��above land surface N �� - ? lines,roads,and buildings. CASINGTYPE(S) � � � � * � � � � --'--- --'-- ---`-- '-- --'--- --;--- ---`-- ---'-- k ELLHEAD COMPLETION ile � th --- --___..._-----__-._----._- .t ,f'r � � �P [ J T ��O er 7 y W W E ��`� •,��1� _ � __;_ _,___ __;__ _ _; _ T ` � Outside: (__I Well House �.�At Grade Inside: ��,_I Basement Offset � , , , , ' Miie "� itless A p r/Und �_]Buried ]Well Pit � P da te --.-- --;--- --.-- -:-- 1 ��Buried ' ' ' ' 'i� U Well Pit S ��.t ',�Other �t nnlie� [�Other PROPERTY OWNER'S NAME/COMPANY NAME CASiNG(S) +.�t�Je Persian Diameter Depth Set in oversize hole? Annular space initially grouted? Property owners mailing address if diflerenl ihan well location address indicated above � in.ffom f �� to f�� ft. �...J Yes ��No �_]Yes '�No I,J�Unknawn in.from to ft. � J Yes � �No [�Yes ❑No ❑Unknown _ in.from to ft. ❑Yes �.J No ❑Yes �No '�Unknown WELL OWNERS NAME/COMPANY NAME SCREEWOPEN HOLE �, / =�� Well owner's mailing address if diflerent than property owner's address indicated above Screen from__ %'- c'�l to f �.J ft. Open Hole from_________to _ _ ft. OBSTRUCTIONS '.�.!Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �J No Obstruction !' .. � Type of Obsiructions(Describe)_ 4 _ _ -=�-- GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �� Yes [__�No Describe_ FOFMATION PUMP , If not known,indicate estimated formation log from nearby well or boring. f� j TYPe---•._...� ,.-Y.�_,r��,d,.,• �1 w�s�.,., — ` ��Removed �_]Not Present ]Other ____ ___ _ _ __ __.__ METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �y,No Annular Space Exists �. .�Annular Space Grouted with Tremie Pipe [.�Casing Perforation/Removal in.from___._________ _to_____.____ft. �Perforated [�Removed in.from to ft. U Perforated [i Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? �,.-�Yes '�No TN#___ _ GROUTING MATERIAL(S) (One bag oT cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material/`�'-�-^ � r�i,..�.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? �,..Yes ._ 'No How many?_ _ , ___ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in acwrdance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best ot my knowledge. Don Stcxlals WeII t�tillir� Co., Inc. 1b91 Licensee Business N e t � License oi Registration No. J,- � '� � . �, .. � r.� a �._".�`.� 'i � restntati e Sigr(g r Certified Rep.No. Date �� _.� - �. �......_. LOCAL COPY H 3��Q� - - —- � 1 "� f _ � 't'y"''—' C,,� n t .��--- --___ ---- v Name of Person Sealing Well or Boring HE-01434-14 IC#140-0423 5n3R � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD 81 O H �J 7 Hennepin Minnesota Statutes,Chapier 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED �rorw 118 23 30 SF Nt� SE, 13� K 1`22-. S �� GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD �"" r' y-^�.�" Latitude Longitude ❑Cable Tool ��, ',Driven � ;J Auger 'hrl'Rotary � House Number,Street Name,City,and ZIP Code of Well LocatioCn n Other �� ' IOUS ?iunt rtl� Rd� D�Q� �J356 � DRILLING FLUID WELL HYDROFRACTURED? �� Ye o �� Show exact location of well/boring in section grid�wiflf' ° Sketch map of well/boring location. ��tQr From "�','-1i.?e�a� tt. ;_ J�� Showing property lines. - N �y f roads,buildings,and direction. USE �Domestic ! j Monitoring '�� ' I—J Heating/Cooling � � � � ,.,j:?°� j '�, �;Noncommunity PWS �_'Environ.Bore Hole '��Industry/Commercial --'--- ---'--- ---`-----`— �' �,�� Community PWS ��Irrigation ❑Remedial --�--- ------ ---=----�-- ,, � levator [�Dewatering ❑ ____ w ; ; ; ; E ��„-��1,' ASIN Drive Shoe? ��Yes �No OLE DIAM. !`' ❑E T C G MATERIAL H --�--- --�--- --�----%-- �j �Jl Steel [;Threaded Lj Welded --�--- --�--- --�--�—:— I de - — - 'M y + + ,�Plastic [� _ 1 1 �4'� CASING S � � t f�>.,�" Diameter Weight Specifications i 1 Mile� l��`� V''~� � in.To �� ft. _____Ibs./ft. _ � in.To ��ft. . -�.f�" � �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. __ Ibs./ft. __ _ __in.To____ft. Steve/Kathleen Pecsian in.Ta ft Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN�y��___ OPEN HOLE JVtlk Make _—. From_ ft. To_ ft. Type__s�_ n ess $ �e. Diam. Slot/Gauze �111 V __Length_�� Set between 13� _ ft.and__��fL FITTINGS�_�� STATIC WATER LEVEL 7n Measured from � � ,ft.`-,�Below ❑Above land surface Date measured� ' WELL OWNER'S NAMEiCOMPANY NAME P;M�ICG LEVEL(below land surtace) � 'n i G J 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/adapier manutacturer_�+�}'►itE+LJ3CEar Model �.�J Casing prolection _ �2 in.above grade f-1 At-grade �.�Well House �.�i Hand Pump GROUT INFLO—RMATION lspecify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_ '-KintQnitrrom �j To �`� ft. �, ,.�_ ❑Yds. '�Bags Material_��tu[a f�„I__5� ro_ 130 n. L;vd5. �-'�;sa95 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 � topsoil black i�n 0 2 M �t n t _ feet _._ � direction RpS)f�[� type �t_�_��-- $$Illl� Cl$� brown �� 7 �+� Well disinfected upon completion? �'es '_�No G PUMP 7 1 !� ��Not installed Date installed_ �-2h'15 Clay d�8� �1� �� Manufacturer'sname___�I'�1. � � sa��L+la� hrQ�•� i1.E71 75 (�C Model Number __ ___ _HP 1 s J Volts_GJU J 1 Length of drop pipe jo�_ ___ft. Capacity g.p.m. 9��d!ClBy re� ,.edium .QiS �,�,� Type:�� Submersible '� �L5.Turbine �]Reciprocating ❑Jet �J. ABANDONED WELLS sa� re�. soft 1.l S 13� Does properry have any not in use and not sealed well(s)? ��' 1 Yes o VARIANCE Was a variance granted from the MDH for this well? iJ Yes � � o TN# WELL CONTFACTOR CEFTIFICATION I This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. I 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. Aoc� _Stodola Well Arillin��Co�_Inc. 1691 ___ _ Licensee Business Name ,✓`� Lic.or Reg.No. .%� -----',-, �' _ _,l ��--- �- �ie e esentative Signature � Certified Rep.No. Date �10�5 7 ��h sr�Qz� I LOCAL COPY _— _ _--- � Name of Driller � � r;;140-0020 HE01205-15(Rev.8/13) . , l Minnesota State L�aboratory ID#027-053-119 TWI11 Clt�/Wat@P C�1171C L8b01'atOP�/T@St Rep01"t wisconsin state I.aboratory ID#io5-1o1i7 Wisconsin DNR Lab ID#399073400 Client: Don Stodola Well Drilling Report Number: 15-01776 TWltl Clty WeteP CI1111C 117C. Sample Collection Date: 02/12/15 61713th Avenue South Address: 3841 North Main Street Sample Collection Time: 13:0o Hopkins, MN 55343 st.Bonifacius,MN 55375 Sample Receipt Date: 02/13/15 Phone: (952)935-3556 Report Issue Date: oz/16/15 Fax: (952)935-5077 Laborato Analy#e Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 15-01776 Coliform Drinking Water 02/13/15 12:31 Absent 15-01776 Nitrate/N Drinking Water 02/13/15 13:05 ' <1.0 mg/L 15-01776 Arsenic Drinking Water 0�/13/15 8:15 02/16/15 10:19 Q.0 µg/L . Lead Drinking Water µg/� Nitrite/N Drinking Water mg/L Drinking Water Drinking Water X No samples were subcontrected;or the above test result(s) Well No.: 810857 with'**'designation were produced by a subcontreded Sample pt: Well laboratory._, Well Adr. 1005 Huntfarm Rd;Orono,MN [I.aboratoryhame;address;MDH Lab ID#]. Owner. Steve Perisian The subcontractedJaboratorymaintains MDH Certificatio�for the field(s)of testing perFormed. Owner Adr: Sample Conditions: Sample Temp: 7°C Discussion: Notes: pprove met o s use in ana yzing t e samp es listed above have the following reporting levels: Maximum contaminant levels: SM9222B-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate Nitrogen 10.0 mg/IL SM4500F or EPA 353.2-Nitrate Nitrogen, 1.0 mg/ qrsenic,10.0 µg/L L SM3113B-Arsenic,2.0 Lead,15.0µg/L µg/I, Lead,2.0 µg/L Nitrite,l mg/L EPA 353.2-Nitrite Nitro en 1.0 m L " ��' ,f�� .,,�-� Sample Collected by: X Client _TCWC Approved By: ;�"��!f `" `=�'�`'-"�-- "` "- Bill Van Arsdale Alan Senechal Laboratory Manager SeniorAnalyst The results listed in this report apply only to the above listed samples.All routine quality assurence procedures were foL'owed,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