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HomeMy WebLinkAbout2015-01400 - Demolition Permit CITY OF ORONO * 2 0 1 5 - 0 1 4 0 0 * � 2750 KELLEY PARKWAY DATE ISSUED: 10/30/2015 ORONO, MN 55356- (952) 249-4600 FAX: (952) 249-4616 ADDRESS : 300 SIXTH AVE N PIN : 25-118-23-41-0001 LEGAL DESC : UNPLATTED 25 1 18 23 : LOT 000 BLOCK 000 PERMIT TYPE : DEMOLITION PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : DEMO- PRINCIPAL STRUCTURE ACTIVITY : 645-SINGLE FAMILY HOUSES(ATT& DET NOTE: I. FOUNDAT[ONS/ALL DEMO DEBRIS"1'O BE REMOVED�ROM GROLTND&DISPOSED OF OFF SITB,PGR PCA REGULAT'IONS. 2. WELLS MUST BE ABANDONED. 3. [NSPECTIONS DONE BEFORE BACKFILLING. NOTE: A 24-48 HOUR N07'ICE IS REQUIRED FOR ALL INSPECTIONS. CALL(952)249-4600. DEMOLITION PRINCIPAL STRUCTURE,TENNIS COURT,SHED APPLICANT DEMOLITION - PRINCIPAL STRUCTURE 75.00 STATE SURCHARGE DEMO 1.00 BURNS EXCAVATING, INC. DEMOLITION -ACCESSORY STRUCTURE 100.00 3470 CO. RD 2l TOTAL 176.00 MAYER,MN 55360- (612)685-4303 Payment(s) Minnesota State License#: SW-1888 CHECK 26888 176.00 OWNER STICKNEY,GEORGE 201 EAST LAKE STREET WAYZATA, MN 55391- AGREEMENT AND SWORN STATEMENT The work for which this permit is issued shall be performed accordina to the approved plans and specifications,applicable City approvals,and the State Building Code. This permit is for only the work described and does not grant permission for additiona]or related work which requires separate permits. All provisions of laws and ordinances governing this type of work shall be compied with whether or not specified herein.This permit will expire and become null and void if construction authorized is not commenced H�ithin I 80 days of the date of issuance,or if construction is suspended for a period of 180 days at any time after work has commenced. The applicant is responsible for assuring all required inspections are requested in conformance with the State Building Code.This permit may be revoked at any time for due cause. � �/ / — C> e�`t� ! '�-�, ���C,� /� � ��� /� Applicant Permitee Signature Date Issued�'y ignature Date O Cityf Of OlO�IO -/ C NLY c�� � � P O.8oz 66 Date Received' it Il �L'_�l � 2754 Kelley ParkwBy ��� �, Crystal Bay,MN 55323 Amount S��-�v — SAC Cr�dit .___.�__ � (952)249�600 �, ,�` Homcowr�er(s)Sigmd. ❑Y�s E' �,� Rtsolutions(if arry)Sigrxd 0 Yes 0 Nosx Requiml ��KESlipR� � Zoni Uiscloswe Si Yes None Re uircd CITY OF ORONO - DEMALfTION PERMIT (Atl permlts musl be approved by ihe Building Offictai and/or ZoMng Department) Job Si#e/Owner Informatian: Type: �esidential ❑ Commercial Site Address: �f�Q C.D_VY1'�7�1 �{�Q(G� �O Owner: ���e�'j 'C` MailingAddress: ZOf �.��,�_S�• city: v�1 G���-� z;p: 55 3"1 / Phone� �52 . y 7 �!. ����� Email: �S�GI�-V1�C lI (� CSg1,cY►'►��I • �M Contractor/Appl'scant lnforma�on: � � �,1�:.'�r.,t�,� Urr� ( �/ Contractor/App.: � �Contact'F�rson: ��?� Address: 3��7c.� �'�a f��l � I State License#: City: Zip: ���(1 Expiration Date: Phone: .s�pve �1�'�.. ��S=`/3 2� Email: SPEGIAL CONDITIDNS & HOLD HARMLESS A(3REEMENT General tnstructions: 1. You may be required to obtain other permits, i.e.:well abandonment, sewer, etc. 2. Wotic must not begin unfess the permit card is availabEe on the job site. 3. A 24-08 hour notice is required for all inspections. Call(952)249-4600. 4. Sewer must be discont�nued at the City service by quat�ed contractor before demo permit is issued. Demolition by means of: ❑Manual Oisassembly ❑ Heavy Equipment ❑Other Permit(s) Issued: ❑ Sewer Oisconneciion ❑Well Abandonment# In return for issuance of said Demolition Permit,the undersigned owner hereby agrees to: 1. Submit a survey, aerial photo or sketch showing all structures on the property. Note which structures are to be demolished. 2. Submit a survey, aerial photo or sketch showing propased erosion control measures in accordance with Chapter 79, Constructian Site Runoff Contml. 3. Submit a copy of pertnit approvai from the Minnehaha Creek Watershed District {MCWD}. The City wili not issue a demolition permit without a copy of the permit(s) from the MCWD or dacumentation stating permit(s)a�e not required. Form Last Updated: Juty 2015 150784 4. Submit a$2,50Q escrow and an escrow agreement signed by the property owner(copy attached}. 5. Keep all structure{s)enclosed andlor secured until such�me as demolition is complete. 6. Keep all demolition debris off adjoini�g property and/or the public rights-of way unless speciftc prior approval is obtained in writing for temparary use thereof. 7. Completely remove foundation(s)�rom the ground. 8. Completely dispose of all demolition debris off site in accordance with all applicable PCA requirements. 9. Abandon water wells in accorclance with State Health Department regulations. 10. Call far an inspection when all debris has been removed, before backfifling. 11. W+thin 5 working days of superstructure removal, a final inspection shall be requested. The site shall be left clean and clea� af all debris, with any excavaGon filled with ea�th leve! with the adjacent ground eleva6on (except when such excavation is to be used as part of a new building and such new building is actually und�r canstruction). 12. Abandon septic systems per Minnesota Rules Chapte�7480. Ail septic tanks must be pumped, crushed and filied with native soils. An inspection is requi�ed after the tanks are pumped and before the tanks are crushed and filEed. 13. The unde�signed owner shall and hereby does indemnify and hoEd harmless the City of Orono, its agents, employess and assigns from and against all claims, damages, losses ar expenses, including attorney fees, against the City, its agents, employees and assigns arising out of or resul�ng fram the demolifion described herein as performed by the property owner, his employees, agents, subcantractors or assigns. PERMIT TYPE AND FEE CALCULATION � $75.00— Principal Structure $ 1 5 [� $50.00—Accessory Structure x�^(how many} 1 o v �E. Subtota! of above permit requested $_ � �,� �D 2. State Surcharge 1 AO 3. T�TAL PERMIT FEE (add lines 9-2 above) $ �� 7 6� �� The undersigned herby applies to the City af�rono for issuance of a Demolition Pennit, agrees to do all the work in a strict accordance with the ardinances of the City and the regulations of the State of Minnesota, and certifies that all statements made on this application are complete, true and correct. Agplicant's Signature: �/ y I/u� Date: o t '� Ow�er's Signature: l Date: 9 ""` �S� ,�'r��t� ,�*r C. �. G Approved By: Date: (Building Official) *Zoning Disclosure Requi�eci? ❑ YES � 'This must be filled out by Zoning Depa ent—For either a r, a Zoning Official must sign all applicati s. *Approved By: Date: � 3� �S� (Zoning O c' } Form Lsst Updated.• July 2015 150784 10/23/2015 Hennepin Counry GIS-Printable Map _ � � � i �c�nn���a, • �,� ,� _ �;>� ` - ` � Y ' � �' �� 9� , � , r, + ,�t ,i ;�i.. `�� �.� . �''���"'� '��-, -�: , ^�" � ,,��.�" x'�� I f�f I� �, +� ��i�'i�li � , �" � �'i; Ai. � .�` . .a � '��R "'�t r -,c.,- � I � ���"* C� ' � :,� �4" '" '. °�� . -:.i£ � �' ��` . +z '�^�a'.�p �.r��' � , .. ,—.. , � i .+ta, - . . , . :a< � �� � . ,,�� ��_. . .. . . � . ,. ���� � �� .,a . . , ., �� . . . . . . � �#: . + ' a �+� . � . ... yRr -;FF1� _ . � . �,.? _�".�'�. . - 8 �r•.. �' � ^'� A�"�''�w��:j����,���9b'+.�� �. ��I I �, w4 ' . �Y f, !i-, f�F � �'r' � � ,.�,`� 9Mw `r � �� '.` � .. � �,rp � i�' '� i � � � � � +�,� �� ,. �" � y � � . ..,;. .. . - � . ,�.�-,. � r,; � .. � �� � � .`'�;. 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N ID: �Print Date: 10/23/2015 Owner Wendy White Dayton Market $4,955,000 Name: Total: Parcel 300 Sixth Ave N Tax $41,734.88 � Address: Orono, MN 55391 Total: (Payable:2015) Property Residential Lake Shore Sale Typ@: P�ICe: This map is a compilation of data from various sources and is fumished "AS IS"with no : Home- Sale representation orwarranty expressed or Homestead im lied, includin fitness of an articular stead: Date: p� 9 y p ; purpose, merchantability, orthe accuracy and completeness of the information shown. Parcel 80.72 acres Sale Area: 3,516,039 sq ft COde: COPYRIGHT OO HENNEPIN COUNTY 2015 f —�....�.rr.,,-...i � https://gis.hennepi n.us/Property/pri nUdefault.aspx?C=458421.2643226198,4982722.013845024&L=6&T=aerial&D=true&LID=O&F ID=2511823410001&VIS=0,0,0... 1/2 � Burns Excavating, Inc Esti m ate 3470 County 21 Mayer MN 55360 Date Estimate # 10/20/2015 2637 Name /Address George Stickney 201 East Lake Street Wayzata, MN. 55391 C/O Coldwell Banker Burnet Project Mooney Lake Description Qty Cost Total Tear down house and remove all concrete and 84,500.00 84,500.00 footings from structure. abandon septic system, remove tennis court and extra buildings per discussion with George, price includes retaining walls and well building does not include capping well project on Mooney lake Remove portion of existing drive per plan 21,500.00 21,500.00 Thank you for your business. Total $l06,000.00 Signature Phone# Fax# 952-955-3112 952-955-5071 5ign-In Sheet Mooney Lake Pre-Construction Meeting City oF Orono . October 27, 2015 Name & Organization Address Phone# Email Address Representing Orono, MN 952-249-4622 Office Mike Gaffron, City of Orono Cell MGaffron@ci.orono.mn.us Fax 952-249-4661 Office Adam Edwards, City of Orono Orono, MN Cell AEdwards@ci.oronamn.us Fax 952-448-8838 Office Dave Martini, Bolton & Menk Chaska, MN 612-756-4315 Cell davidma@bolton-menk.com Fax Art Taylor, Bolton &Menk Chaska, MN Office 612-756-2048 Cell artta@bolton-menk.com Fax 952-955-3112 Office Steve Burns, Burns Excavating Watertown, MN 612-685-4303 Cell steve@burnsexcavating.net Fax Mark Gronberg, Gronberg & 952-473-4141 Office Associates Long Lake, MN 612-759-3082 Cell markg@gronbergassoc.com Fax George W. Stickney, BPS 952-476-3694 Office Properties, LLC Wayzata, MN 952-250-1075 Cell gstickney@cbburnet.com 952-216-0055 Fax Office Gage Chaffeee, TBI Chanhassen, MN 612-991-6634 Cell gage@terrybros.com Fax 612-321-5435 Office Cherie Monson, CenterPoint Energy Cell cherie.monson@centerpointenergy.com Fax Office Cell Fax L �*�.��" ��� H:\ORNO\C 13109539\15-3739_Mooney L.ake Preserve�Pre Con Sign L Sheet.doc ���'���� � Page_of_ " '� . = BO LTON 8� M � N K , I N C� � . Consulting Engineers & Surveyors �� 2638 Shadow Lane, Suite 200 • Chaska, MN 55318-1172 Phone (952)448-8838• Fax(952)448-8805 www.bolton-menk.com Preconstruction Meeting Agenda Project: Mooney Lake City of Orono, MN Date/Time: October 27,2015 Place: Orono City Hall Attendance: Please complete sign in form when passed around Purpose: Introduce involved parties; identify their involvement and their contact people. Review contract requirement, expectations and establish protocol. Owner: Private City Contacts: • Mike Gaffron, Senior Planner o mgaffron@ci.orono.mn.us o (952) 249-4622 • Adam Edwards,Director of Public Works/City Engineer o aedwards@ci.orono.mn.us o (952) 249-4661 • David Martini, Bolton &Menk o davidma@bolton-menk.com o (612) 756-4315 • Art Taylor, Bolton &Menk o artta@bolton-menk.com o (612) 756-2048 Owner Contacts: • Georbe Stickiiey, BPS Properties General Contractor: • Gage Chaffee, TBI List of Subcontractors: • G & M Tree Removal • Burns Excavating, Demolition • Bituminous Roadways, Blacktop � CR Fischer, Curb and Gutter List of Suppliers: • TBD • Gage will supply City with list of suppliers before work begins � Shop drawings will be sent to Mark Gronberg before work begins H:AORNO\C13109539\15-3739_Mooney Lake Preserve\Pre Con Minutes.doc � � • � BO�TON 8� M � N K , I N C� � . Consulting Engineers & Surveyors �� 2638 Shadow Lane, Suite 200• Chaska, MN 55318-1172 Phone (952)448-8838• Fax(952)448-8805 www.bolton-menk.com Plan Revisions: • Final plan set dated 10/17/15 • Project scope includes: o Road construction (approximately 500') o Cul-de-sac construction o Driveway constructiou (approximately 300') o Mountable curb and gutter o Pond co»struction o Infiltration basin construction Landscaping Plan: • Entry monument • Teunis court improvements • Cul-de-sac center � Tree plantings Construction Schedule: • Approximately 8 days of work (weather depending) • Tree removals have begun • Equipment will be delivered to the site this week • Septic sites need to be fenced off before work begins • Work can begin once Plat is recorded (potentially Thursday or Friday) • Art Taylor should be kept ii7formed of project schedule • Art Taylor needs to be present for all test rolls including subgrade • Work on Prairie View will be completed as time allows Utilities: • Utilities will be installed in joint h�et�ch • Existing gas will need to be removed in location of pond and existing driveway • No road crossings are expected • Gas is located on east side of Hunter to serve lots • Small utilities will likely be installed next spriug due to time ofi year • Hennepin County will not allow work in the right of way after first snow fall • Xcel will serve new lots so new service will be required • Owuer will plan for temporary service to serve home construction tl�is winter • Small utilities need to be called out on the SWPPP Permits: NPDES MCWD Hennepin County • Copies of permits need to be provided to the City before work begins Financial Securities: • Bob Bean is reviewing cost estimates and will provide the City with security recommendations today H:\ORNO\C13109539\15-3739_Mooney Lake Preserve\Pre Con Minutes.doc ' - • = BO LTON 8�- M � N K , I NC� � . Consulting Engineers & Surveyors �� 2638 Shadow Lane, Suite 200 • Chaska, MN 55318-1172 Phone(952)448-8838• Fax (952)448-8805 www.bolton-menk.com Easements: • All easements and right of way are shown on the Plat • Rain gardens that will be constructed on individual lots will need an approved plan and associated easement at the time of building permit Project Safety:Project safety is the Contractors responsibility. The General Contractor is responsible for their Subcontractars actions. Public Safety: Construction sites can be an attractive nuisance. Worker Safety: OSHA Competent Person - Gage Chaffee Sanitary Facilities: To be provided by the Contractor. Maintenance and Control of Traffic: Maintenance of traffic is the Contractor's responsibility. • Construction traffic will be contained to the development site • It is the Owner's responsibility to meet all Hennepin Couuty Requirements far work in the right of way and traffic control Storage/Staging: • Staging and storage will be contained to the development site Construction Concerns: • Access � Dust • Street cleaning • Parking � Rain Garden Construction Erosion Control: In place prior to start of construction. Must be maintained throughout construction. • Double silt fence is needed in buffer and wetland areas Other: • Attorneys will discuss determine who will record the Plat H:AORNO\C13109539\15-3739_Mooney Lake Preserve\Pre Con Minutes.doc C.�YC�Q � � DATE TIME CITY OF ORONO CALLED IN � /� INSPECTION NOTICE SCHEDULED PERMIT NO. COMPLEfED ADDRESS �C� c /v OWNER TELEPHONE NO. 55 �a CONTRACTOR ( � i'�--� �l'� , � DESCRIPTION � `'���� �� `( �l/L t~y ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL,T/l/LO Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLIN O ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVA Z ❑ RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTI � Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ RATED WALLS/� � ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT v"���/� Q ❑ FINAL ❑ WATER HOOK-UP ❑ FOLLOW-UP 41 ❑ AS BUILT-SURVEY ❑ EWER HOOK-UP ❑ FOUNDATION/REMOVAL _ � ❑ DEMO-SITE EPTIC INSTALL 2 OWNERICONTRACTOR TO MF.�Y�OU: YES_NO � � COMMENT5: � .t --� .� � C l — a "' o r p e nf o ��� '' �r•:ti ���;,, �rosqo ti Ca•-c.�%t'oL � 0 � W � Q � 2 � W � J W�RKSATISFACTORY:PROCEED ❑PROJECT COMPLETE � ❑CORRECT WORK&PROCEED ❑ISSUE CERTIFICATE OF OCCUPANCY W 0 O CORRECT WORK,CALL FOR REINSPECTION TEMPORARY V BEFORE CONERING PERMANENT ❑CORRECTUNSAFECONDITIONWITHIN HOURS. ❑ pHOTOTAKEN INSPECTOR WILL RETURN ❑STOP ORDER POSTED.CALL INSPECTOR �CITATION ISSUED ❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS. Cail for the next inspection 24 hours in advance. (g52) 249-4600 OMrnerlCorrtractor on site: � Inspector: �"� White CopyAnspector's File Canary CopylSite Notke DATE TIME CITY OF ORONO cnLLED IN INSPECTION NOTICE SCHEDULED 7 PERMIT NO. �� ��f y� COMPLEfED �/ �l ADDRESS ��� �*� ��• y OWNER TELEPHONE NO. CONTRACTOR ��r�S ��a�� � � DESCRIPTION � -�� 4~j ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLING O ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVAL Z ❑ RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTION Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ RATED WALLS � ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT Q INAL ❑ WATER HOOK-UP FOLLOW-UP W ❑ AS BUILT-SURVEY ❑ SEWER HOOK-UP ❑ FOUNDATION/REMOVAL _ v ❑ DEMO-SITE ❑ SEPTIC INSTALL ? O'WNEAICONTRACTOR TO MEET YW:_YES_NO � COMMENTS: ��rrrl�� `l-d`�e�i ��•/�� � G�y 4 U✓ A �i� i �9 5.���ie:� j o , � I��i��p Co�A��r�e — �� ��r�s �' � �✓'��2 i''e�lUvc� �'✓o.�- S.� � Q �x�va�,dr, /��s 6i�� .6�L'�//��9 — Z �Qr�. s �i�.d.� ��e�0�� -_ � � � �2s'��� �-�i'l��e�O � � ❑WORKSATISFACTORY:PROCEED ROJECT COMPLEfE W ❑CORRECT W'ORK 3 PROCEED ❑ISSUE CERTIFICATE OF OCCUPANCY O ❑CORRECT WORK,CALL FOR REINSPECTION TEMPORARY V BEFORECONERING PERMANENT ❑CORRECT UNSAFE CONDITION WITHIN HOURS. p pHOTO TAKEN INSPECTOR WILL RETURN ❑STOP ORDER POSTED.CALL INSPECTOR �CITATION ISSUED ❑INSPECTION REOUIRED.CALL TO ARRANGE ACCESS. Call for the next inspection 24 hours in advance. (952) 249-4600 OwnedContractor on site: Inspector: ���"' � Whits CopYAnspector's Flle C�nary CopylSks Notks „ . _, ..�. MINNEHAHA CREEK WATERSHED DISTRICT QUALITY OF WATER QUALITY OF LIFE INSPECTION REPORT DATE: 2/19/2016 7h�;+�ir�n.ehcna Creek TO: George Stickney w/atershec!�astr�ct is FROM: Lauren Sampedro, District Representative ca�rrrr�itte�to a RE: MCWD Permit# 15-445: 300 6t''Ave N, Orono leadership rvte rn Dear Applicant, protecting, impraving The Minnehaha Creek Watershed District(MCWD) has inspected your site for compliance with the and m�r�agir�g t�� MCWD permit requirements. Based on our inspection at the above mentioned location,the su,�a�c wa�e�s rrr�c! following was observed and recorded on February 18, 2016: a��(�nted c�roundwater . Non-functioning perimeter control around demolished home resourres wirhin the • Unstable slopes near existing driveway Dist�ic�, inctuding their MCWD requests that the following corrective actions are taken: r�tnta��nships tca[h�> • Re-install and maintain perimeter control around entire property, especially around demolished ���"S�$��tr�� ��`�t"��' ��'�� home near Mooney Lake (see attached picture) are on integral part. • Stabilize slopes next to existing driveway to prevent further soil slumping (see attached picture) Vi'e achieve our missian �fj+�������'�{��Q�j�+�, To avoid formal enforcement action from the Minnehaha Creek Watershed District, please c�rrartat�rb��r,,;�:, implement the above mentioned corrective actions as soon as possible. edutarion, coop2rative Thank you for your attention to MCWD permit requirements. If you have any questions, please er�deavors, ar��othe� contact me at 952-641-4580 or Isampedro@minnehahacreek.org prograrrrs bras��1 csn Respectfully, snur�d scierr�t�, ���U/l,Q/1�, Q��(Tv'Yh���/� ir;nov�:tive thinking, an Lauren Sampedro informed arad eragar�er,' District Representative G�nerstrG�aPnr.y, and tfrr> ca.s��f�ectpve use nr �ub(ie fier,ds. _ � _ ^ MINNESOTA UNIQUE W�LL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTFi AND BORING NO. ' co��,y Name "} WELL AND BORING CONSTRUCTION RECORD g 18 0 3 6 �.����n Minnesota Statutes,Chapter 10.3I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED `,e Orono 11�3 23 25 N,� S"GJ� SE ,� 2^� K 7-1-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven ❑Auger �Rotary Hg�use NurPbser,�re�et Nrar e, 'ty,�r�ZIP Code of Well Location '�Other Tettcli �. DRILLING FLUID WELL HYDROFRACTURED? j I Yes No S ow exac o tion o we/ ring in section grid with"X° Sketch map of welUborin location. �ter From ft.To ft. Showing pro rty lines, � N roads,buildings,an direction. USE �Domestic ❑Monitoring [I Heating/Cooling F •. __j____j___ _.�____;_ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �'. � ❑Community PWS �Irrigation �J Remedial ❑Elevator ❑Dewatering ❑ w E �� � CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. ��- ; � � � � + ""'""' --�--- ---�-" ---'-- T hreaded elded F � �,Steel �T ❑W ',�� ; , '/Miie �°r���l� ,r��"���� Damleter��Plastic ❑ ; S 1 Weight Specifications i 1 Mile� � � in.To ��ft. Ibs./ft. �in.T�ft. ,� i Z PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �.Tq�ft. Caldwell �3Anker T3uc-net-G�eocge Stickney :�i/t3 ca� in.To ft. Ibs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. 2� Z$g ZQ�, �',, �$�C@ St Make From ft. To ft. t��3 Z�3t8 f''�i1 55391 Type Diam. Y 7 SIoUGauze Lengfh Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from c F . ��___ft. Below �Above land surface Date measured ��1""IC7 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) RECEIVE� 23� ft.after � hrs.pumping �O g p m. Wetl/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION APR 0 4 �(� � !�Pitless/adapter manutacturer Model �"�•' �_'.Casing protection �12 in.abovye grade [j At-grade ❑Well House ❑Hand Pump �.nita aS,�l .y��F��ONo GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) MaterialbenCOniLe From � To��Q ft. � ❑Yds. �Bags Materiall��.��Z ���� �0 To L�"'ft. �Yda [J Bags HARDNESS OF Material From To ft. ❑Yds. �J Bags � GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags r t NEAREST KNOWN SOURCE OF CONTAMINATION �I�y ��� ��'� � 2j' ��� feet �" direction � � � t—� type $� C $}� rQ� � Well disinfected upon completion? �i Yes [,'No 4 san�ly c2ay �ray mec�iwn 36 98 PUMP � a! �n � � � � sa [;Not installed Date installed ��21�16 ��� �CQWIl � Manufacturer's name c ay �;ray um A sandy 'l.'�laj� �r$� SQit i�5 233 ModelNumber L HP G Volts 230 �n y � 8y �r8y $Q Length of drop pipe �v� fL Capacity g.p.m. (��.Y'ty S$P���j[a�tQ j��{ �t�,�i'�! 253 2`J! Type: Submersible ❑L.S.Turbine ; ]Reciprocating ❑Jet ❑ ABANDONED WELLS 41if.'8CCR1L �2 OW SL ...• b�� Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE . Was a variance granted from the MDH for this well? ❑Yes No TN# WE�L 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. Don Stocio2a Well Drilli Ca . Inc. 1691 Licensee Business N me Lic.or Reg.No. '� 12-21-15 rtifi epresentative ignature Certified Rep.No. Date ` Q Iy�1� ^{ Rob StaiOla " . L�CiAL Ci�PY . - ... (J 1 V�O J� � Name of Driller . . .. ID#52603 HE-01205-15(Rev.8/13) r . � � " ` Minnesota State Laboratory.ID#027-053-119 Twin City Water Clinic laboratory Test Report : ;W�sconsin State Laboratory ID#105-10117 � `��;.r=�:Wisconsin�DNR Lab�ID#399073400 � �� CIi211t: Don Stodola Well Drilling Report Number: 17-02a05 Twin City Water Clinic Inc. �� Sample Collection Date: 02/28/17 617 13th Avenue South , i Address: 3841 North Main Street Sample Collection Time: 10:00 Hopkins,MN 55343 st.sonifacius,MN 55375 Sample Receipt Date: 03/Ol/17 Phone:(952)935-3556 Report Issue Date: 03/o2/i� Fax:(952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date .' Time Date , Time Results Units 17-02405 Coliform Drinking Water 03/Ol/17 12:51 Absent 17-02405 Nitrate/N Drinking Water 03/Ol/17 11:41 <1.0 mg/L 17-02405 Arsenic Drinking Water 03/O3/17 9:30 03/02/17 11:15 4.76 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L E.coli Drinking Water ; well No.: 818036 X No samples were subcontrected;or the above test result(s) Sam le t with""designation were produced by a subcontracted p p � Well � laboretory. [Laboratory name;addresr„MDH Lab ID#].The Well Adr: 300 County Road 6;Orono,MN subcontracted labvratory maintains MDH Certifiwtion for the - Owner. Coldwell Banker Burnett field(s)of testing performed. ` Owner Adr: Sample Conditions: Sample Temp: 8°C Discussion: Notes: Approved methods used in analyzing the samples listed above have • the following reporting levels: - Maximum,contaminant levels: . SM92228-Coliform,1 cfu/S00 ml Coliform-<1 cfu/100 ml ° EPA 353.2-Nitrate Nitrogen expressed as NO3+NO2,1.0 mg/L Nitrate Nitrogen 10A mg/L ACsenic,:10.0 µg/L SM31136-Arsenic,2.0µg/I,Lead,2A µ�/L �• EPA 353.2-'Nitrite Nitrpgen,l.0 mg/l Lead,15,0µg/L_ ', Nitnte,~�1 ing/L��� � Sample Collected by: X Client _TCWC Approved By: , "�� � ��-- ,�~� Bill Van Arsdale Laboratory Manager The resulu listed in this report apply only to the above listed samples.All routine 4ualityas;urance procedures were followed;uoless otherwise noted.This analytical report must be reported in its entirety.All methods are cert�ed by the Minnesota Department of Health;unless otherwise noted. � TCWD Rev 4.0 Page 1 of 1 .. , ��'��w� '�' `��::V , � � � � �.```�.��r�� r �. _ _.,�.,..�� � �����'�:� �_< P ,�` .��-� -�_ � L 7 y , { � .. " � � �c' ,� � � e� 'l � }� ll .i' � j! R; � �1.� .�..� 1 ,.� + �,J� � , 1� _ . f�,y7,� �y� �� �',+s iuL'� �� � t w'ic.. 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