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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA UNIQUEWELL MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG ND. co„��YName WELL AND BORING RECORD � �, �� Minnesota Statutes,Chapter 103! � �� Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED / n. GPS DRILLING METHOD Latitude degrees minutes seconds LOCATION: Longitude degrees minutes seconds i _Cable Tool ��,J Driven ! ��Dug —— , ,Auger �otary .. j Jetted House Num�St�eey N,��CitH,�d Zip Code of Well Location � or Fire Number i _ �1T �J� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �Rlo Show exact location of well/boring in section grid with��X:' Sketch map of well/boriny,Jocation. From ft.To ft. ��S howing p�r QBrty lines, N =� ��r� oads,T)uildings,�nd;direction. USE �IDomestic �:�:Monitoring ��J Heating/Cooling ,, �. _1__ _; __L_ ._.__ ; �~ , . � > i I Noncommuniry PWS I�Environ.Bore Hole �.�':Industry/Commercial —� �""�` � � :. �_,Community PWS =Irrigation ��Remedial — --i_ 1 � :. i �' i`�Elevator '��Dewatering �] w ; ; , ; e � � � CASWG MATERIAL Drive Shoe? �]Yes �Vo HOLE DIAM. --,--- --,--- --�----:- T i - ;*.. '`,Steel [j Threaded ❑Welded � � � � �F Mle _,�,� - � - �.!S , , , , � T '�� lastic , -'�--- —T— --�----�- � : .� � � � � CASING � � S � � � Diameter Weight Specifications �--1 Mile—� �� _� in.to 1 Gt,__ ft. Ibs./it. _. Q_�in.to_�ft. ZV'� f7w� PROPERTY OWNER'S NAME/COMPANY NAME . in.to___...._ft Ibs./ft __ 6 ! in.to•'T+'!ft �r �7 T 7.fL in.to ft. Ibs./ft. in,to ft. SCREE� OPEN HOLE ' Property owner's mailing address if different Ihan well location address indicated above. �7J�y_� �--�� 4p�qL �s n�t„� Make�s".�'•w•�t .__.___.._ From ft. To ft. _� laJL�F i'li�t� aT1tlCt Type�1�1'��5��.`� $�'� Diam._ � . ��$� � S��I, Slot/Gauze_ . __ _.—_.—._ _Length_.�.�_�� __ � Set between ft.and ft. FITTINGS STATIC WATER LEVFL 13r Measured from � ft.' Below �]Above land surface� Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after •J hrs.pumpin g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ;� '�+.1Pitless/adapter manufacturer a��;ta�a�e�ir.� . Model ,..: �]Casing Protection_ �'I2 in.above grade .At-grade(Environmental Well and Boring ONLY) � GROUTING INFORMATION we�� No ,� � �� Grou�m'a er��* [c ryeni�8enronit t�oncrete �_�O er_ ___ 6aaa. 1 ��1 To Z ft. _ I ,Yds. ��Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_,__ To ft. ,�'Yds ,J Bags MATERIAL From To ft. f�Yds. I l Bags _ NEAREST KNOWN SOURCE OF CONTAMINATION _ f��`�•- � ._feet {.�-� direction �e��S... type �� Well disinfected upon completion? ,�Yes I I No PUMP � �Not installed Date installed_.._7�1.�� ._. _.. .._ Manufacturer's name_ ��'f+,�r _ .__ Model Number ____. HP__ ��_Volts_ � Length of drop pipe __��7 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. � ��g *�� s��a� ^w'• ��# *�� w, �C 1 1 l.+f.7 1 Licensee Business Name � Lic.or Reg.No. �_,�.� f� � �' d �presentative Signature Certified Rep.No. Date �r�c��coPv � � 3 5 0 6 �or�;ers� tdeil Co., r�/�o��a w. ��r� Name of Driller IC 140-0020 � HE-01205-12(Rev.12/08) . . . � � � , , Minnesota State Laboratory ID#027-053-119 Wisconsin State Laborato ID#105-10117 Client: Field Engineering Report Number: ii-o9e� Twin City Water Clinic Inc. Sample Collection Date: oe/zs/ii 617 13th Avenue South Address: 7608119th Lane No Sample Collection Time: is:oo Hopkins,MN 55343 Champlin,MN 55316 Sample Receipt Date: oe/z9/ii Phone:(952)935-3556 Report Issue Date: oe/3o/ii Fax:(952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 11-05729 Coliform Fi1-164 Drinking Water 06/29/11 14:59 Absent 11-05729 Nitrate F11-164 Drinking Water O6/29/11 13:19 <3.0 mg/I 11-05729 Arsenic Fii-164 Drinking Water 06/29/11 11:35 06/30/11 12:40 2.25 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water X No samples were su6contracted;or the above test result(s) Sample Conditions/Discussion/Notes: with""deslgnation were produced by a subcontrected laboratory. Sample Location-783506/Well 155 Mackinnon Dr.Orono,MN [Laboratory name;address;MOH Lab ID#]. Kyle Hunt&Partners 18324 Minnetonka Blvd Minnetonka,MN The subcontracted laboretory maintains MDH Certificatfon for the fleld�s)of testing performed. 12°C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the sampies This Sample meets the ' Maximum contaminant levels: listed above have the following reporting levels;; State of Mfnnesota, Coliform-<1 cfu/100 ml SM9222B-Coliform,1 cfu/100 ml Wiscon;in and EPA Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen,1.0 mg/I guidelines for safe Arsenic,30A µg/I SM 3003-Arsenic,2.0µg/I Lead,is.0µg/I drinking water for the SM3113-Lead,2.0µg/J analytes tested. � �.t,�c.Lr'.a-t� �.. �. Sample Collected by: X Client _TCWC Approved By: ; ��Z f Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst The results listed in this report apply only to the above listed samples.All routine qualityassurance procedures were followed, unless otherwise noted.This analytical report must 6e 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