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Home My WebLink Aboutwell info MINNESOTA DEPARTMENT OF HEA�TH M�nnesota Well and Boring � � •, WELL OR BORING LOCATION Sealing No �"� �4,��s County Name WELL AND BORING SEALING RECORD Mmneso'a Urnque No. -- �@L�nE�Iil Mmnesota Statutes,Chapter 1031 or W-ser�es No. J I_� ILeave blank il np�known) Township Name Township No. Range No. Section No. FracOon(sm.-►Ig.) Date Sealed Date Well or Bormg ConsVuded cJrono 117 23 Q7 14—d415 3c3 El�'i�'-�- ^� Numerical Street Adtlress or Flre Number and Gry of Well or Bonng l.ocanon �f 1y�*Linden Lane, ��0�� 553b4 DepthBeforeSeahng ff� , R OngmaiDepih C/� t n Show exact location of w�ell oi bonng Sketch map of well o�onng UIFER(S) STATIC WATER LEVEL in section grid with`X'. locahon, showing p perty Single Aywfer ❑ Multiaquder lines,�oads,and buii ngs. N WELUBORING Measured ❑ Estimated . . � � � � .� ~��--,_ Water SupD�Y Well ❑Monit.Well r � � � � �. �..� -r' -T- '�- -'r- �� . ��. �/ . � � � � `{�� ❑ Env.Bore Hole ❑Other _ ��-y R. [[a�below ❑ above land suAace � � � � �' - W -�- -i-- -i- -- -- E ... Q CASING TYPE(S) � � � � , � � � -�-- -;-- -i-- ---{-- � Steel ❑ Plastic �Tile � Other u mde � � � � � CASING -�- -�-- -�-- --1-- Diameter' Depth t�� Set in oversize hole7 Annualar space initially grouted? S �{ ��,�� , in.from� to R. ❑ Yes ��No ❑ Ves ❑No ❑ Unknown P P TY O ER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown �y�e �as�erik 472-4846 Properry owner's maiGng address if tllflerent than well location atldress indicated above. in.from to ft. ❑ Yes ❑ No ❑ Ves ❑No ❑ Unknown SCREEWOPEN HOLE� 1�V / Linden Laz�e Screenfrom�to � �� ' fl OpenHolefrom to ft. �Y. oesTaucnoNs WELL OWNER'S NAME Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑/ Fill ❑ No Obstruction Well owners mailing address it ditlerent Man properry owner's atltlress mdicated above. Typ6 ot ObSl�udions(DeSC�ibe) `��'�t�` • -^�� `• Yf _ Obstruclions removed? �'es ❑ No Describe PUMP Type OEOLOOICAL MATERIAL COLOH HARDNESS OF FROM TO � Removed �] Not Piesent ❑ Other FORMATION - It rat krawn,indicate es�imated fortnatbn log from nearby wel�or bonng. M�EyT�,HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: AJ No Annular Space Exists ❑ Annular space grouted with tremie pipe �� Casing Perforation/Removal in.from to ft. ❑ Pertorated ❑ Removed in.irom to fl. ❑ Pertoreted ❑ Removed Type of perforalor ❑ omer CaROUTING MATERIAL(S) f, i Grouting Material N�f��f ��i/,�,�FOm Q to �� it. � yards bags from to ft. yards bags from to ft. yerds begs from to-- R. yards begs REMARKS,SOURCE OF DATA,DIFFICUlT1ES IN SEALING OTHER WELLS AND BORINGS 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 wiM Minnesota Rules,Chapter 4725. The infortnation coMained in this repoA is true to the best of my knowledge. Don Stodo2a Well Dcillf.n Co. , Inc. 27172 Contrector Business Name License a Registretion fio. " / �f' � f' ��. j r,✓�( ori R resentative Signatiira'"" Oete � m '�n�'c�r�saY, � - �-�q Name o Person Sealing Well or Bonng � LOG1L COPY H HE-01434-04 8�98 R . I � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. '?� �� Coun;y Name WELL AND BORING RECORD - .. . . . �� ._, .-, f�� r?�n��ar;in - Minnesota Statutes,Chapter 1037- J J !� •_� �) Township Name Township No. Range No. Section No. Frection WEWBORING DEPTH(completed) DATE WORK COMPLETED �'Conc� ll7 ?_3 07 ,,cF. SF IVF, n. GPS DRILLING METHOD Latitude degrees minutes seconds LOCATION: — -- q�� [I Cable Tool i]Driven r:�� ;,,,, Longitude degrees minutes seconds �1 qu er Rotar �b,�' House Number,Street Name,City,and ZIP Code of Well Location 9 I�� Y ��`'� [I Other �r T DRILLING FLUID WELL HYDROFR�CTURE ?, [�No • t Show exact location of well/boring in s ction grid with"X:' Sketch map qf welUboring location. i7�[ From ft.To ft. - SlMowing property lines, ` N roads,b ildings,and direction. USE �Domestic ❑Monitoring ❑(}}}��lgiatin��ic�� ` __L_ _ ____..�_ ...__ � ��Noncommunity PWS '� I Environ.Bore H01e`�]�iGstry/Commercial i � ,p�� n []Community PWS _j Irrigation v ❑Remedial � � --1--- � � � �� T '' ❑Elevator � ;Dewatering ❑ --'-----�-- ---`-- ' 9 .� � ' W ; ; , ; E � b - ASIN MATERIA Drive Shoe? �]Yes �Na OLE DIAM. � �`_ C G L H --,--- --.-----�-- ---:-- T �.�.. � , �]Steel ��Threaded ❑Welded - ' , , , , Mile - ,� ., , , , , � '.-�-- ��,Plastic r J_ ' --�-- —�------�— --1— '-� — CASING � 5 � , . Diameter Weight Specifications F--i Miie--� ,_.��____in.To 12� ft. _ Ibs./ft. R in.To J��.n `5. PROPERTY OWNER'S NAME/COMPANY NAME in.To tt. Ibs./ft. +,"k in.To 1��ft c��n� �+r��,� in.To ft. Ibs./ft. in.To n SCREEN OPEN HOLE 4 Property owner's mailing address if different than well location address indicated above. r 23� 1��r±QI rf� Make ��-'�� From ft. To ft. t ,��'' �ttt ,�Z!}n Type stainl�ss St�Q� Diam. �� SIoUGauze f{i'� Length_ (�t _ Set between ft.and_ ft. FITTINGS n STATIC WATER LEVEL � � � ; � Measured from 7��-` ft.j�.Below ❑Above land surface Date measured '�- � 1 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) $� r -� ft.after 7 hrs.pumping �A� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 74,.i Pitless/adaptermanufacturerT`�"��lt`r�c�t#�r Model r'Casing protection [�+12 in.above grade �1 At-grade �]Well House ❑Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement concrete,cuttings,or other) Material��CYSt(]F41t�From_ �To��ft _� [j Yds. [�Bags Materialtlilt'llt"A�I tf'�r�r�,__.��_To_�,Z�ft. [,Yds. f JBags + HARDNESS OF Material . From To R. [i Yds. [J Bags ; GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION CI$j �lE?�TOLvT "t�„°�_� � �7 f_.... feet = _� direction �-.'d.'' :• tYPe f 7 Well disinfected upon completion? es ❑No !�i � t,,:�� .- "`.`�eZ`"��r C1.�> t.ar��' T';ei��L�t`! �� i� PUMP ❑Not installed Date installed ��l��t tx __ _ C1F3.�,S<`2��t� �C`3jr K'1e��.LtE�3 ��Q ��` Manufacturer'sname C;�.��F� ____ _ �_a �r�� t �,�� '� Model Number HP ��1 Volts , FIL: ¢ Length of drop pipe l�l ft. Capacity g.p.m Type:' 'Submersible ❑L.S.Turbine ❑Reciprocating []Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? i_j Yes � � o 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,i1 needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. �n �tc��ol� '�?�11 I�rillin;; ';�,. ��c. �'��'1 Licensee Business Name �-�--- Lic.or Reg.No. .� � ;'�f� �'/ 1-5-1.5 GeEtified Representative Signature Certified Rep.No. Date ., �� . � ; F.� �'c�h SLcs�ol�± i�CA�.CQPY I� .�` � .�lJ Name of Driller IC 140-0020 � � � HE-01205-14(Rev.5/12) �� Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drillin Report Number: ia-ions Twin City Water Clinic Inc. Sample Collection Date: o9/zs/ia 61713th Avenue South Address: 3841 North Main Street Sample Collection Time: ia:oo Hopkins, MN 55343 5t.eonifacius,MN 55375 Sample Receipt Date: 09/29/14 Phone: (952)935-3556 Report Issue Date: 09/30/14 Fax: (952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 14-10728 Coliform Drinking Water 09/29/14 15:12 Absent 14-10728 Nitrate/N Drinking Water 09/30/14 14:48 <3.0 mg/I 14-10728 Arsenic Drinking Water 09/29/14 11:00 09/30/14 14:38 5.53 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water Well No.: 799036 X No samples were subcontracted;or the above test result(s) with'**'designation were produced by a subcontracted Sample pt: Well laboratory. [Laboretory name;address;MDH Lab ID�i].The Well Adr: 1065 Linden Lane;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Swansen Homes field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 6 °C Discussion: Notes: � Approved methods used in analyzing the samples 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/I SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic,10.0 µg/I SM3113B-Arsenic,2.0µg/I Lead,15.0µg/I SM31136-Lead,2.0µg/I , , � , , , � / ,/�� '✓r�,,,�;'/ �.' ��t'a-�� . Sample Collected by: X Client _TCWC Approved By: �: ' �� Bill Van Arsdale Alan Senechal Laboretory 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 certified by the Minnesota Department of Health, unless otherwise noted. TCWD Rev 1.2 Page 1 of 1