HomeMy WebLinkAboutwell info 1` M/NNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
co„��Y Name WELL AND BORING RECORD -7 � � �� �
Minnesota Statutes,Chapter 1037
Township Name Township No. Range No. Section No. Fraction WEWBORING DEPTH(completed) DATE WORK COMPLETED
it.
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude degrees minutes seconds �_�Cable Tool �Driven '�_�Dug
Auger �+Rotary ,_Jetled
House Number,SVeet Name,City,and Zip Code of Well Location or Fire Number ��
DRILLING FLUID WELL HYDROFRACTURED? '�`:�Yes ��. o
Show exact location of we/boring in section grid with"X:' Sketch map of well/boring lo ation. From ft.To ft.
Showing propert lines,
roads,buildings,and dir ction. USE — �
nl �Domestic "Monitoring ��Heating/Cooling
�' __L____:______L_ ___i__ " ❑Noncommunity PWS [�Environ.Bore Hole ❑Industry/Commercial
.� j 1 L i- � ommu y WS ion _- emedial
C nit P �frrigaf �l R
: W , , , , E .�,�;��� �7x�� ASIN IAL aOe�n9 HOLEDIAM.
' ❑Elevator ❑Dew � _ �.
T MATER Drive Sh ❑Yes [�Mo
C G
' ' � � ' �,�" ' ���]Steel ❑Threaded �_J Welded
; , , , , Mile p —
�h
, , , , I lastic ❑ ''
--,-----,-----�-- ---�-- 1
'V ASING
S � � Diameter Weight Specifications
..¢A`
�i nniie� . __.�_in.to���ft. �_i�lbslft. ��� �_in.to_�ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _IbsJft �in.to�.�ft.
in.to ft. Ibs./ft. in.to ft.
Property owner's mailing address if different than well location address indicated above.
SCREEN_ OPEN HOLE
At�1 T,�� c� Make_�i�,.,sarw From ft. To ft.
LVl � lisR� a7t Type Diam. �fw
��ta� PY' S.737� SIoUGauze _ Length
$�tn:^���p�p St1�.•1�Zlc� Set between_. � .and ft. FITTING
t�
STATIC WATER L Measured from
ft � elow ❑Above land surface Date measured
� � WELL OWNER'S NAME/COMPANY NAME PUMPING LpEVEL(below Iand surface)
l�O ft.after ��� hrs.pumping � g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
Pitless/adapter manufacturer . Model
'�.Casing Protection ,��'12 in.above grade
'�At-grade(Environmental Well and 8oring ONLY) � f,
GROUTING INFORMATION �
Well grouted j�7es ' "'J
,J No
Grout materials �J Neat cement�entonite ❑Concrete �,.;Other
From�To�ft. �� ❑Yds. �(6ags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__�To�'�;�") �:. �� j���i'._�gags
MATERIAL From__ To ft. �]Yds. �ags
NEAREST KNOWN SOURCE OF CONTAMINATION
� feet /i� direction - -� type
Well disinfecled upon completion? � s ❑No
� PUMP
I�Not installed Date installed ���. ��i l �
T Manufacturer's name
� Model Number HP � Volts
Length of drop pipe !��1_ � ft. Capacity g.p.m.
Type:�,' Submersible �J LS.Turbine �]Reciprocating `__��,Jet L]
ABA DONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes No
VARIANCE
Was a variance granted from the MDH for this well? [;Yes ��; � No TN#_
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. �
� The information contained in this report is true to the best of my knowledge.
Use a second sheet,if needed.
�� REMARKS,ELEVATION,SOURCE OF DATA,etc. � (�►�.J��$ ��� ��,li�yg '�a'0�• IQC• �6�1
ie«R �.r�
� Licensee Business Name Lic.or Reg.No. I
_ �
� / f �� / x
-- = ...--- _ .
f Repres ntative SignatC�re Certified Rep.No. Date
' (� Q!llC�C �IbO�f.'
a_ LOCAL COPY ��O U� � __ -- —--- --—--—
Name of Driller
IC 140-0020
HE-07205-11(Rev.3107)
�-
.�
Laboratory Test Report
Engel Water Testing, Inc.
9300 County Rd. 15 * Minnetrista, MN 55359
Phone: (952) 955-1800 Fax: (952)955-1806
Minnesota State Certified Laboratory#027-003-105 * Wisconsin State Cert�ed Laboratory#105-10115
Don Stodola Well Drilling Co., Inc.
3841 North Main Street
St. Bonifacius, MN 55375
Water Test Location: Report Issue Date: July 2, 2009
115 Leaf Street Year: 2009
Orono,MN Date/Time: Sample Collection: 6/30 4pm
Date/Time: Sample Recd.in Lab: 6/30 9pm
Well Unique Number: 770014
Laboratory Test Number(s): 09-6779
�Required when critical to the validity and application of the results
1�a�or���ry ; ]�ate!'�'� : �at�'���' Tes� ' ' ',
l�a� E : ����lts Approv�dM�thod �1�es
T�N� ;; �pl�pr�p �nalysts :
_.... ...
::{uarts�:::.. . .....:::. . . >. -.
09-6779 Coliform 6/30 9pm 7/1 9pm Negative SM 9223 B 18�'ED
Bacteria c°�'S"rem
09-6716 Nitrate 6/23 9am 6/23 9am <1.0 mg/I P�ISE Method SM Nitrates Tested
4500-NO3 D 18 ED 6/23/09
09-6716A **Arsenic 6/26 l lam <0.002 ppm �senic Tested
6/26/09
Allowable Limits:
➢ Nitrate Nitrogen,mg/1: Maximum allowable limit is 10.0 mg/1 or Less
➢ Coliform Bacteria: Allowable Limit is NEGATIVE
➢ Lead,ppm:Maxitnum allowable limit is 0.015 ppm or Less
➢ Arsenic,ppm: 0.010 ppm or Less-(0.010 ppm or more exceeds the MDH-recommended health limit for long-term
consumption of arsenic in druiking water.
Subcontracted test results:
� No samples were subcontracted;or
��The above test result(s)with"**"designation were produced by Stearns DHIA Laboratories,825 12°i St.S.,Sauk Center,
MN 56378(NIN Cert.No.027-145-378).The subcontracted laboratory maintains MDH certification for the field(s)of
testing performed.
Discussion/Notes: These test results are within the allowable limits.
Report authorized by: � Date: July 2, 2009
Kathryn M. Engel, Laboratory Dir tor �
The results listed within the report relate only to the samples received on the dates indicated.
This report must not be reproduced,except in full,without the written approval from Engel Water Testing,Inc.
Created by Engel Water Testing,Inc.October,2008 Page 1 of 1