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Home My WebLink Aboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring z g 9 0 3 0 � WELL OR BORING LOCATION Sealing No. H County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. � �Q Minnesota Statutes, Chapter f03I or W-series No. (Leava blank ii not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Oro�no i18 23 36 t�l.► SL� N!� 8 F P 4 . . GPS Latitude__, degrees minutes seconds Depth Before Sealing 2�� tt. Original Depth ft. E' LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Sireet Address or Fire Number and City of WeII or Boring Location � Single Aquifer ❑Multiaquifer ,�/� 517 Fect�ale Rd N, vLVIiE,� WELL/BORING I_�easured ❑Estimated Date Measured Sr4,ir�' �� r, . -�, Water-Supply Well ❑Monit.Well r •�. ` Show exact location of well or boring Sketch map of well or b ` �. in section rid with"X." location,showin n Env.Bore Hole ❑Other �� ft. below ; 9 lines,roads,and bui din � — ---- � l�above land surface nl . CASING TYPE(S) " --'-----i-- --`-- ---'- � � � � � �teel ❑Plastic ❑Tile ❑Other . � " '-'--- --'--- ---`-----�-- WELLHEAD COMPLETION - W ; ; ; ; ET � ' ' _;____r__ Outside: ❑Well House []At Grade Inside: i�asement Offse[ �.��A '/,Miie V�„ ', �.pitless Adapter/Unit ❑Buried � ]Well Pit --�----�------�-- --�— i]Buried � ' S ' �Well Pit j .,--�-ry�q_,,,� rl ❑Other _ �--1 Mile f ❑Other PR�OtPE,RfTY OW!NER'S NAME/ MPANY NAME CASING(S) � YClt R Diame � � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location address indicated above in.from � to ft. i]Yes No Yes �.� [J ❑ ❑No U Unknown 1� Yeit Place in.from to ft ❑ ❑Unknown R�' � �r��k ❑Yes [j No ❑Yes No J Y in.from to ft. ❑Yes ❑No ❑Yes ❑Na '�I Unknown WELL OWNER'S NAMEiCOMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if ditterent than property owner's address indicated above SCreen from to ft. OpOn Hole from z�3 to �.��ft. OBSTRUCTIONS Rods/Drop Pipe j�Check Valve(s) ❑Debris Lj Fill [.J No Obstruction Type of Obstructions(Describe) �i{/�jC �1/� r ��,�/�f) TJ GEOLOGICAL MATERIAL COLOR HaaoNESs oR pROM TO Obstructions removed? Yes �.J No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP �s r� Type�c,��,_�e�j�.t} �"j �� iemoved [_Ji No�resent ❑Other � _ J �....l.-��'F� � ( METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASWGS,OR CASING AND BORE HOLE: ��lo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing PerforatioNRemoval in.from to k. ❑Perforated ❑Removed _ in.from to ft. [�Perforated ❑Removed Type of PeAorator 'r. ' ❑Other _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) .}� r / Grouting Material IV'��lT��tJ{ from � to� ft._ yards�_ bags __ from to _ ft. yards bags _ from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. � Stodala We12. D�illing Co. Ic�c. 269i v Licensee Business me � � License or Registration No. ,v--� � �% ' � �'J � , � ; rti d presentative Sh�nature Certilied Rep.No. Date � LOCAL COPY H �9 9 O 3 O ;��'"�Y�'' �� Y`""� Name of Person Sealing Well or Boring � HE-01434-12 IC#740-0423 g�agq T: _ ; MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. + County Name WELL AND BORING CONSTRUCTION RECORD 818 O O�. � Minnesota Statutes,Chapter 10.?I Towns ip e Township No. Range No. Section No. Fraction WELUBOAING DEPTH(completed) DATE WORK COMPLETED y, n. GPS LOCATION—decimal degrees(to four decimal places). �� DRILL WG METHOD Latitude Longitude . �❑Cable Tool ❑Driven I]Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location i]Other SI7 cC�l� R� ir� OCOTIO 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X:' Sketch map of well/boring loca ?�ntonite From ft.To ft. Showing property I' � roads,buildings,and dire i � USE ` N �Domestic ❑Monitoring ❑Heating/Cooling � ` � � � � Environ.Bore Hole ❑Industry/Commercial --'-- --�------�-- --`-- „j Y Noncommund PWS � *� ❑Community PWS ❑Irrigation ❑Remedial [i'Elevator ❑Dewatering ❑ A, w ; ; ; ; e T CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. --�--- � --�—--.-- ; ------ I Steel �Threaded ❑Welded � '/z Mile f � ❑ � � � � � � � � ' , , , , Plastic ,.. �� r --j-----�-- ---�-- ---�— I CASWG '. 5 L Diameter Weight Specifications �1 Mile� ., in.To�ft. Ibs./ft. �in.To�.q_ft. 1U PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. G1. in.To�tt)ft. �r� Zi� '�G�l�lf �.�t� x�4il�� II�• in.To ft. Ibs./ft. o ft. Property owner's mailing address if different than well location\ddress indicated above. SCREEN OPEN HOLE ry Make From ft. To ft. �J52 ?�icmetonka �1V(� Type Diam. � LG��n� ��T �1-771 SIoVGauze Length Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from ft. Below ❑Above land surface Date measu �'-- WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(be w land surface) - � �� ft.after � hrs.pumping 5� g.p.m. , Well/boring owner's mailing address if different than pro s d i icated above. WELLHEAD COMPLETION ��r :,. Pitless/adapter manufacture Model ; ❑Casing protection �12 in.above grade (�1'1'Y OF ORONO ❑At-grade ��Well House ❑Hand Pump ' GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Matenal�t��EFrom � To 5V ft. �__ �]Yds. ags Material�t�81 �� 50 To 214 ft. [�Yds. �]BBags HARDNESS OF Material From To ft. n Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From To __Bags , C�B� �ra�1 ��1;� O � NEAREST KNOWN SOURCE OF CONTAMINATION 1 ��r� �J,� � / _,.1' feet /� direction �-a -��-x-zw`type i r, �} We�l disinfected upon campletion? Yes �j No �i7U brc�m. s�oft l 21 pUMP J'�Not installed Date installed �1�j�� clay/�ancd r+�dd r,�c�fwn 21 41 —�c1�on$ld Manufacturer's name * yravel/�erarx� i 1X C(�r� [}� 1i2 Model Number HP 1�5 Volts_ Length of drop pipe �2�7 R. Capacity g.p.m l�y�� .'ray jtie�� ,1'G Z�8 Type:' Submersible ❑LS.Turbine ❑Reciprocating �Jet ❑ AB D NED WELLS ��Ci�yl 6ravel [Qi,1 TT�(.11j]�'j 12g 212 Does property have any not in use and not sealed well(s)? ❑Yes �No VARIANCE `�gt�� y [E�1t�t1$iLi l.11 243 Was a variance granted from the MDH for this well? ❑Yes No TN# WELI 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. Stodola Wel Dri � Licensee Business Name Lic.or Reg.No. ? �-' 12-8-15 . .., r ' d re t tive Sig'nature Certified Rep.No. Date Rob StodOla f f. LOCAL COPY 8 18 Q 0 1 - �� Name of Driller ID#52603 HE-o1205-15(Rev.8/13) E s - � r �, ' Minnesota State Laboratory ID#027-053-119 Twin City Water Ciinic laboratory Test Report wisconsin State Laboratory 1D�i 105-10117 Wisconsin ONR Lab ID#399073400 Client: Don Stodola Well Drilling Report Number: i5-i32iz Twin City Water Clinic Inc. Sample Collection Date: 11/10/15 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: �i:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: ��/��/�s Phone: (952)935-3556 Report Issue Date: �i/12/15 Fax:(952)935-5077 Laborato Analyte Client'ID Parameter 'Sample Prep Sample Anafysis Test SamplelD Date Time bate Time Results Units 15-13212 Coliform Drinking Water 11/11/15 12:01 Absent 15-13212 Nitrate/N Drinking Water il/il/15 12:05 <1.0 mg/L 15-13212 Arsenic Drinking Water 11/11/15 8:50 11/12/15 11:47 5.11 µg/L Lead �rinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water Well No.: 818001 X No samples were subcontracted;or the above test result(s) with'*"designation were produced by a subcontracted Sample pt: well laboratory. (Laboratory name;address;M6H Lab ID#]. The Well Adr. 517 Femdale Road N;Orono,MN subwntrac4ed laboratory maintains MDH Certiflcation for the Owner: Denali Custom Homes field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 10°C � Discussion: Notes: Approved rnethods used in'analyzirtg the samples listed Maximum con#aminant levels: above have the following reporting levels Colifarm-�1 cfu/100 ml SM92Z2B-iCaliform,1 cfu/100 ml < Nitrate Nitrogen 10.0 mg/IL ' SN14500F or EPA 353.2-Nitrate Nitrogen,1.0 mg/l i Arsenic,10.0 µg/L ' SM3113B=Arsenic,;2.flµg/I,Lead,2.0 µg/L Lead,15.0µg/L EPA 353.2-Nitrite Nitrogen;1.0 mgJl IVitrite,1 mg/L ' �' ' �!t� ..c.r.stic''� Sample Collected by: X Client _TCWC Approved By: l�`''�'t��/� `=� Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst TMe resultsJisted in this report,apply only to the a6ove 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 MianesotaDepartment of Health;unless otherwise noted. _ TCW D Rev 2.0 Page 1 of 1