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Home My WebLink Aboutwell info �:��;:�.::�� ,R � . .- , ,_. r .., . ,.. . - .... _ ._ _ , -:. ._. . . .. � - � . __ � . , MINNESOTA UNIQUE WELL ;: WELL�IR RORINa LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. v� County Name WELL AND BORING RECORD 7 8 8 2 4 8 �p� Minnesota Stat es,Chapter 103I Township Name Ownship No. Range No. Section No. Fraction WELUBORWG DEPTH(completed) DATE WORK COMPLETED �L'��'� - Z.1,7 23 �7 � �: �'�a n � GPS �, (� DRILLING METHOD LOCATION: �Latitude degrees minutes ___ seconds _____ Longitude degrees minutes seconds I�Cable Tool ❑Driven --- ❑Auger �(Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑p�her 15t�5 North Arm Dr, VL�F�Eb lSa[7�! ` DFILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo ti �ter From ft.To ft. Showing propert e , N roads,buildings,and dir 1�. USE �Domestic ��Monitoring ❑Heating/Cooling " __J___ __�__ __1____`__ ]Noncommuniry PWS ❑Environ.Bore Hole ❑Industry/Commercial �Community PWS ❑Irrigation ❑Remedial � --i--- --'--- ---F-----t- j_�Elevator ❑Dewatering ❑ ��. W , , , ; E� CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. 1 . --�--- -�-- , --�--- - --%-- - ._ ❑Steel ❑Threaded ❑Welded �� --�--- --�--' '--�-' --:" ile ��M 1 �Plastic ❑ ; ; ; ; CASING S ` Diameter Weight Specifications _lW � in.To �� ft. Ibs./ft. � in.To �ft �1 Mile� _____ ' J"• �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJfL �in.To��ft (�taclea/Jennifer Cogbill in.To ft. Ibs./ft. _ in.To ft SCREEN � OPEN HOLE Properry owner's mailing address if different than well location address indicated above. ��-- � Make From ___ft. To R. Type��_�t� Diam.__ SlovGauze � � �� Length�_______ Set between ft.and tt. FITTINGS A i } STATIC WATER LEVEL Measured from__ ft.�i Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) � 165 ft.after � hrs.pumping �v g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �„�f t��e� �]Pitless/adapter manufacturer��l� __ _ Model ' ❑Casing protection ,�12 in.above grade ❑AFgrade ❑Well House LJ Hand Pump GROUTING INFORMATION(specity bentonite,cemenbsand,neat-cement,concrete,cuttings,or other) Matenal ��Vtii��rom � To .7� ft. � ❑Yds. �Bags Material��E1t"$1 f�al�.— ,gl_To�ft. ❑Yds. ❑Bags HARDNESS OF Matenal_ _____From__ To ft. ❑Yds. �]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��11� bi� $�ft 0 3 � �� feet �f1 direction �',. "X-_'` -`. ' ' ''"tyF�'e ��+ +� s} Well disinfected upon completion? �Yes ❑No C1A �� t�JCCLII�I} d `7 PUMP ttJCCLl Lj Not installed Date instailed /'.. � C�a �� "'" Manufacturer's name_ �� _ _ _ __ ��a �� Q Model Number HP�l�Volts_�_ Length of drop pipe 1G� ft. Capacity g.p.m � t8� �� *�p Type.f� Submersible I�LS.Turbine ❑Reciprocating ❑Jet ❑ a �' ABANDONED WELLS �1 �t.� ��s� 1 TD !85 Does property have any not in use and not sealed well(s)? ❑Yes No 33i7Fgx �.A �C.R.11 1/�7 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dan Stoda►Ia We1I tk�illin� Co_,_._Iric. I691 i. Licensee Business Name Lic.or Reg.No. _ �t��/J �� -�-iz resentative Sig�r re Certified Rep.No. Date L_��:EaL ti;�r,.. 788248 � �t� Name of Driller IC 140-0020 HE-01205-13(Rev.11/10) f � ` Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drilling Co Report Number: i2-iiii Twin City Water Clinic Inc. Sample Collection Date: os/si/iz 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time:, ss:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: oe/oi/iz Phone:(952)935-3556 Report Issue Date: os/oa/iz Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 12-05732 Coliform Drinking Water 06/OS/12 12:47 Absent 12-05732 Nitrate/N Drinking Water 06/01/12 12:03 <1.0 mg/I 12-05732 Arsenic Drinking Water 06/Ol/12 9:00 06/04/12 11:58 12.40 µg/I Lead Drinking Water µg/� Drinking Water Drinking Water Drinking Water X No samples were subcontracted;or the above test result(s) Well No.: 788248 with'*"'designation were produced by a subcontrected Sampie pt: laboratory. Well Adr: 1505 North Arm Dr Orono,MN [Laboratory name;address;MDH Lab ID#]. The subcontracted laboratory Owner: maintains MDH Certification for the field(s)of testing Owner Adr: Sample Conditions: Sample Temperature: 18 °C Discussion: Notes: Approved methods used in analyzing the samples This Sample does not listed above have the following reporting levels: Maximum contaminant Ievels: meet the State of Coliform-<1 cfu/100 ml SM92226-Coliform, 1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I Minnesota,Wisconsin SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic,10.0 µg/I and EPA guidelines for SM 3003-Arsenic,2.0µg/I Lead,15.0µg/I safe drinking water for SM3113-Lead,2.0µg/I the analytes tested. , �.L,,/ `Gle�.c:S1e��cl�t"a � Sample Collected by: X Client _TCWC Approved By: ,,r ° L� 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 certified by the Minnesota Department of Health, unless otherwise noted. TCWD Rev 1.2 Page 1 of 1 ` WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �O�H i '7 County Name WELL AND BORING SEALING RECORD M nn�egoNa Unique Well No. ��i� Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank�it not knownJ Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed orora 117 23 07 �E �E �Z , GPS Latitude degrees____ minutes seconds Depth Before Sealing__�ft. Original Depth ft. LOCATION: Longitude degrees_____ minutes seconds AQ �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location . . ingle Aquifer ❑Multiaquifer t� 1505 North Acm Dr, � 1�.7�.�Y C �'/ELL/BORING �1Qeasured ❑Estimated Date Measured JM��y_ �Nater-Supply Well !_]Monit.Well I Show exact location of weil or boring Sketch map of well or b � C in section grid with"X." location,showing prope .Env.Bore Hole L]Other ��+.._.. ft. �elow ❑above land surface N lines,roads,and building � �� CASING TYPE(S) --'--- --'-- --'-- --'-- 7 j j j j . Steel ❑Plastic ❑Tile �,_';Other � --'--- --�-- ---`-- ---'" �• �Y � � WELLHEAD COMPLETION W � � � � E ,�7 _ ..,,. � � � � T " � Outside: :`�Well House [_J At Grade Inside: ❑Basement Offset ; ------ ------ ---�-- ---*-- ;; , , , , Mile dless A p dUnit ❑Buried ❑Well Pit i� " —�--- --;-- ---;-----;- I 1 �+ _ Buried �P da te `� D ' ' ' ' L \ �]Well Pit S � ❑Other �1 Mile-� .� ❑Oth2f PR/p�P�E�RTY WNE/g' NAME/ PANY AM CASING(S) �++�C�e$I��e�� Diameter � Depth ( Set in oversize hole? Annular space initially grouted? Property owner�s mailing address rf different than well location address indicated above ��in.from � to 1�ft. ❑Yes �No []Yes '��No ❑UnknoWn in.from to ft. ❑Yes ,!Na ❑Yes ❑No ❑Unknown in.from to ft. �J Yes ❑No ❑Yes ❑No ❑Unknown � WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if diNerent than property owner's address indicated above SCreen from��to�ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe U Check Valve(s) ❑Debris � ��Fill �No Obstruction Type of Obstructions(Describe) ____._ __ GEOLOGICAL MATERIAL COLOR HARDNESS OFi FROM TO Obstructions removed? ❑Yes ��; ]No Describe FORMATION PUMP If not known,indicate estimated(ormation log from nearby well or boring. � � �� Type ��Removed �Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE 'z �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe !�Casing Perforetion/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other _„__ GROUTING MATERIAL(S) (One bag of cement-94 Ibs.,one bag of bentonite=50 Ibs.) . wfc �yy! f�/ / /� � Grouting Material r��f/��from V to �� ft. yards��L bags s from to _ ft. yards bags from__ to ft. yards bags OTHER WELLS AND BORINGS r REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING o 0 Other unsealed and unused well or borinr�on property. ��Yes o 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 ta the best of my knowledge. ; non sc�ociola r�ell Drilling co,. Inc. 1691 r�- Licensee Business N e License or Registration No. �-�'' _ � ; �. �-�� !� Ce ied pre entative Signatur Certified Rep.No. Date LOCAL COPY H �0 2 8 7� — {� �'�'r``� — k Name of Person Sealing Well or Boring � HE-01434-12 IC#140-0423 " g�agR