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Home My WebLink AboutBackflow preventer test .:;_a—. . �: _ . . _.._.. _._ .r _ ,.__ .�.__._._; . . __, �_ . . . .. _ ,. . _ .� ... _ .,. WELi OR BOR7NG LOCATION MINNESOTA UNIQUE WELL MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD S 18�21 Minnesota Statutes,Chapter 103I Township N• e Township No. Range No. Section No. Fraction WELUBORING DEPTH(compieted) DATE WORK COMPLETED ,� 138 h. 3-19- GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool �❑Driven House Number,Street Name,City,and ZIP Code of Well Location .❑ahe r �Rotary ocT o 5 2 0�� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes � No Show exact ocation o we/boring in sectio g id with"X:' Sketch map of well/boring location. �c �$C From_ .��R�NO ft. Showing property lines. N �/ r �..�bifiidh�qs,and direction. USE �Domestic ❑Monitoring [!Heating/Cooling ' , � , � N- �.�.-�. �.- � � � � �'�' ❑Noncommunity P S ❑Environ.Bore Hole ❑Industry/Commercial W i -- -- ---- -- --- - �� __ � " ? ; ; ,� � ❑Community PWS ❑Irrigation emedial r-,R f --�-- --;-----}-----�-- ,r�¢ []Elevator ❑Dewatering [� . � I W ; ; ; i E� CASING MATERIAL D ive Shoe? ❑Yes �lo HOLE DIAM. f ' ' f ,/z Mile ❑SI2StiC � ' -- -- -- -------- " ��Threaded ❑Welded ------------ ---�----:-- 1 CAS W G � � S � Diameter ^ Weight Specifications ��M�te� ��1��'�� in.Ta �G� ft. Ibs./ft. � in.To � PROPERTY OWNER'S NAME/COMPANY NAME in.Ta ft. Ibs./ft. �in.To 13 . in.To ft. Ibs./ft. in.To ft. ro e y ow r's mai ing a dress i(ditferent than well location address indicated above. SCREEN OPEN HOLE Make �n From ft. To ft. 18215 45th aDe fi�, Ste D Type stainiess �teel Diam. Lll�p�t[!� i'si� Sj.7[,��] SIoUGauze �a�,Q �Length t}� ♦ �}! J.�,.�.� ' Set between tt.and ft. FITTINGS � 1 STATIC WATER LEVEL Measured from ft. elow ,']Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after_, hrs.pumping g.p.m. ` Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer��E�,��e� Model ❑Casing protection �12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT W FORMATION(specify bentonite,cemenFsand,neat-cement,concrete,cuttings,or other) Material �tV17it�rom 11 To SQ n. 3 �Yds. �ags Material n$�r$Z ��,_ �To 129 ft. �Yds. �Bags HARDNESS OF Material From To ft. ❑Yds. [�Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From __To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��7 feet _.i' direction '' � type Well disinfected upon completion? .Yes J No PUMP �J Not installed Date installed "'+IS-I�i Manufacturer's name Model Number HP 1.J Volts Length of drop pipe 1't7 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 o 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,eta � , � J Licensee Business Name _��,/' � ic.or Reg.No. `�'�� :r�f� ` �-' � �Z7�I�i "rtified epresentative Signature Certified Rep.No. Date " Q Adt3 Stfl(�018 �-�CP`�-C'�PY 8 1 Q o� � Name of Driller ID#52603 HE-01205-15(Rev.8/13) r�:, Minnesota State Laboratory 1D#027-053-119 TWI11 Clt�/Wat@P C�IIIIC LafJOP8t01'�/TeSt_R@p01't wisconsin state l.aboratory 1D#105-1o1v Wisconsin DNR Lab ID#399073400 - Client: Don Stodola Weil Drilling Report Number: 16-02963 Twin City Water Clinic Inc. Sample Collection Date: os/zo/ie 61713th Avenue South Address: 3841 North Main Street Sample Collection Time: i5:oo Hopkins,MN 55343 st.Bonifacius,MN 55375 Sample Receipt Date: 03/21/16 Phone:(952)935-3556 Report Issue Date: 03/22/16 Fax:(952)93�-5077 Laborato Analyte Client ID Parameter Sample Prep : Sampie Analysis Test Semple;FD Date Time Date Time Results Units 16-02963 Coliform Drinking Water 03/21/16 12:01 Absent 16-02963 Nitrate/N Drinking Water 03/21/16 10:58 <1.0 mg/L 16-02963 Arsenic Drinking Water 03/21/16 7:10 03/22/16 9:54 6.60 µg/L Lead Drinking Water µg�� Nitrite/N Drinking Water mg/L Drinking Water Drinking Water ' Well No.: 818021 X No samples were subcontrected;or the above test result(s) with'•*'designation were produced by alsubcontrected ' Sample pt: Well laboratory. [Laboratory name;address;MDH Lab ID#]..The Well Adr: 425 Lakeview Parkway;Orono,MN subcontracted laboratory maintains MDH Certiflcation forthe Owner: Norton Homes field(s)of testing performed. ' Owner Adr. Sample Conditions: Sample Temp: 17°C Discussion: Notes: Approved:methods used in analyzing the samples listed Maximum contaminant levels: ' above have the following reporting levels: Coliform-z 1 cfu/100 m� SM92226-Coliform;1 cfu/100 ml Nitrate Nitrogen 10.0 mg/IL ' SM4500F or EPA 353.2-Nitrate Nitrogen,1.0 mg/L ' ' Arsenic,10.0 µg/L SM3113B-Arsenic,2.0µg/I;Lead,2.0 µg/L - Lead,15.0µg/L - EPA 353:2-Nitrite Nitrogen;1A mg/L Nitrite,1 mg/L Sample Collected by: X Client _TCWC Approved By: T ��.��! ��t=�°��."`'"� 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 assurance procedures were followed>unless.otherwise noted.This analytical report must be reported in its entirety.All methods are ceitified by the Minnesota Department of Health,unless otherwise' noted. TCWD Rev 2.0 Page 1 of 1