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Home My WebLink AboutWell & Boring Record r r � . :�.. . . . _ . . . . . � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD r �� n Minnesota Statutes,Chapter 10.3I �? � `��" � � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED t�rono 117 23 � S,� SHj SW,, I 25 n IO-28-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑CableTool ❑Driven � � �� - �� ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location I]Other �7 F$LYl.��e� Arr� 5539! DRILLINGFLUID WELLHYDROFRACTURED?,.�YAs' . No Show exact loc n of well/boring in section grid with"X" Sketch map of well/boring I af��pppppp111 �$t�� From ft.To___,. ft. �a�v i rp�.1 ��e Showing propert lin�, Vrr roads,buildin and di c . USE N k. �Domestic ❑Monitoring e g/ i � , , ,.s __;__ __;_._ ___�__ __,__ a �;�j ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ) ❑Community PWS ❑Irrigation ❑Remedial __�_____�_-- --;_-_;__ { �Elevator ❑Dewatering �J w ; ; ; ; e CASING MATERIAL Drive Shoe? HOLE DIAM. , , , , T ❑Yes �No --�-----;-----�-- --�- I ❑Steel ❑Threaded ❑Welded ; � ; ; ,1M ; ; ; ; Plastic ❑ _„" --�------�-- ---�- ie ' ; ; ; CASING � S Diameter Weight � Specifications e ` 4 ii5 h. Ibs./ft. Q in.To 5�. �1 Mile—� in.To -\ ''. �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To �"�"ft. ��r� �.�� in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 32U� �'art�or Lsne Make � � From ft. To ft. P� t �T 55447 Type stainles� steel Diam , � ' � � SIoVGauze �� Length �} ♦ 4 Set between ft.and ft. FITTING � � STATIC WATER LEVEL Measured from ft. Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) / I�� fl.afte� � hrs.pumping `�O g.p.m. WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t��-itQS��r ��PiUess/adapter manufacturer�M�4 Model ❑Casing protection �12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neabcement,concrete,cuttings,or other) Material t�ilt�l3��From � To lVft. ❑Yds. �Bags Matenal nstural f�l�_�To 115ft. �Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION Cj�� C�� '� �� feet /+� direction _ :—� �v,�_.� Well disinfected upon completion? �Yes ❑No , sacidy clay gcay i�m 1� 61 PUMP j c n ❑Not installed Date ins[alled_ �,��J O�l� �1� `� ��"� Manufacturer's name �[ici hrawn .i� IQ� �2S Model Number HP�Volts Length of drop pipe � ft. Capacity g.p.m Type: Submersible `�-'�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 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. Dor� Stodo2a We11 Drillin� Co,. Ir�. ib91 Licensee Business Name Lic.or Reg.No. `- - ,,/� .. �` �z-1�-�6 =t -� -- rfi Re esentative Si ature� Certified Rep.No. Date Rob Stod018 LOCAL COPY g 2 3 4 L�.4 -- — V' Name of Driller ID#52603 HE-01205-15(Rev.B/13) Minnesota State laboratory ID#A27-053-119 TWI11 Clt�/WatEC C�1111C LabOCatOP�/TESt RBpOrt wisconsin 5tate Laboratory ID#to5-1o117 Wisconsin DNR Lab ID#399073400 Client: Don Stodola Well Drilling Report Number: 16-15866 Twin City Water Clinic Inc. Sample Collection Date: 10/30/16 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: �a:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 10/31/16 PhOne:(952)935-3556 Report Issue Date: �i/o�/�e Fax:(952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID ' Date Time Date Time Results Units 16-15866 Coliform Drinking Water 10/31/16 13:51 Absent 16-15866 Nitrate/N Drinking Water 10/31/16 14:04 <1.0 mg/L 16-15866 Arsenic Drinking Water 10/31/16 8:30 11/01/16 13:24 30.20 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water - Well No.: 823444 X No samples were subco�trected;or the above test result(s) Sample pt: Well with'**'designation were produced by a subcontracted labo�atory. [Laboratory name;address;MDH Lab ID#J. The Well Adr. 3099 Fairview Lane;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner. Laura Gibson field(s)of testing performed. ' " Owner Adr: Sample Conditions: Sample Temp: 8°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 J 100 ml Nitrate Nitrogen l0A mg/IL SM4500F or EPA 353.2-Nitrate Nitrogen,1.D mg/L ' Arsenic,10.0 µg/L ' SM3113B-'Arsenic,2.0µg/I,Lead,2.0 µg/L ; Lead,15.0µg J L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/C ^. 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 aesurarace procedures were followed,unless otherwise ' noted.This analytical report must be reported in its entirety.Allmethods are certified by the Minnesota Department of Health,unless othervvise noted. _ TCWD Rev 2.0 Page 1 of 1 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �� 419 0 County Name , WELL AND BORING SEALING RECORD Mennle90 a�Unique WeII No. • Minnesota Statutes,Chapter 1031 or W-series No. (Laeva Wenk il not Iviown) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �' �k,1 GPS LOCATION—decimal degrees(to four decimal places) / Depth Before Sealing /(�� ft. Original Depth ft. Latitude Longitude AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 31�39 Farvie�a I.�ne, �rQ� 55391 W LUBORING Measured ❑Estimated Date Measured_'�J��'� Water-Supply Well ❑Monit.Well ��j r 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 �ft. �'below ❑above land surface lines,roads,and buildings. N ��u CASINGTYPE(S) � --'-- --'------`-- —_'_ ' ,.,.J teel ❑Plastic ❑Tile ❑Other ' ' - '-' - '-- � � WELLHEAD COMPLETION - '- - -'-- -`- - W � � � � E __�___ __�,__ _._;_ .__�__ T � Outside: ❑Well House ❑At Grade Inside: [J Basement Offset I 'e �itless Adapter/Unit ❑Buried ❑Well Pit " " " ' ❑Buried ' T S ' ' � ^ ❑Well Pit p`�"' ❑Other �1 Mile� pl ❑Other 0 V7 PROPERTY OWNER'S NAME/COMPANY NAME � CASING(S) f i Diameter Depth Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diHerent ihan well location address indica�ed above //. � � in.from�__ to //Y� ft. ❑Yes �No ❑Yes ❑No ❑Unknown 3205 Harbor Lane • -` � Ply�r�azth, � S��Y7 in.from to ft. []Yes ❑No ❑Yes ❑No ❑Unknawn in.from to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE i Well owner's mailing address if diNerent Ihan property owne�'s address indicated above Screen from_ //Y� to � ft. Open HOIe from to ff. YY�`�- OBSTFUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris (-1 Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS oa FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. Type __ �`- � ❑Removed �Not Present ❑Other ff 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 ot 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.) Grouting Material _ �from�_ to��j&_ ft. yards�_ bags 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? ❑Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The intormation con[ained in this report is true to the best of my knowledge. '�on �todala Well Drilling Co,. Inc. 1�i91 Licensee Businers N�ne i � License or Registration No. y � .� r' fj ,, j _ �;�� r /j' �- �_ �/Ce�dff resentative Signat e Certified Rep. ate c �`"' " �� 90 � ,�, LOCAL COPY `�`'`--�,. ."`' �� j ✓`i-.S'�`, Name of Person Sealing Well or Boring HE-01434-14 ID#53159 .. 5n3R