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Home My WebLink Aboutwell info '�~��. ' . F,(� ��b MINNESOTA UNIQUE WELL V�ELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTF�'(� '�� AND BOR/NG NO. CounryName WELL AND BORING �CORD�.q , ,,�} . � . . i � Minnesota Statutes,Chapterl��Y _, ��Jt` i.,7 �v'1-"r �: � � Township Na �e Township No. Range No. Section No. Fraction WELL/BORING DEPTH(complet2d);'�. DATE WORK COMPLETED 09 �kJ A14a'y,SW �� }4� �`�.�" 11-12�'ll1 G � DRILLING METHOD LOCATION: Latitude degrees minutes seconds " Longitude degrees minutes seconds ❑Cable Tool ❑Driven -- ❑Auger ��Rotary House Number,Street Name,Citg and ZIP Code of Well Location ❑Other l� �A� �tQ�tii ?t90t'�' �C� t�r0� 55391 DRILLING FWID WELL HYDROFRACTURED? �,.=�Yes ��, No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. ��t�,-�-�� From ft.To ft. a Showing property lines, ' N � � 9 �Domestic ❑Monitoring ❑Heating/Cooling .'� �;io s,buildin s,and direc�ion. USE _ __ _ � ,� J Noncommunity PWS _]Environ.Bore Hole ❑Industry/Commercial \ ��j �� ❑Community PWS _]Irrigation ❑Remedial ' -�-- --`- -' ❑Elevator ,]Dewatering ❑ � W ; ; ; ; E . �,/ � CASING MATERIAL Drive Shoe? ❑Yes Na HOLE DIAM. ..�: � '-- ---�-----'-- T �^' ..Y�+. �� f-,_,l Steel U Threaded U W�ed ,- - ' � � <% ,- -�---—._ '@ Miie �.i"�� ..... � Plastic ❑ 'i - 1 �� CASING � � � S � �� r Diameter Weight Specificatwns � . � � f—�Miie� �� in.To �� ft. Ibs./ft. � in.To ��ft ___ -- -— — ------ ��-�q PROPERTY OWNER'S NAME/COMPANY NAME _______in.To ft. Ibs./ft. " in.To�ft �',�.ke �,�al 1�� in.To ft. Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE �.� Make Jfl}ijZ�Qj� From ft. To ft. ` Type �r�ecsr�2��5•��Diam. p ' �-�---�----_..._ r SIoVGauze Length I_f {, t.� s �f Set between ft.and ft. FITTINGS d STATIC WATE L Measured from � ft. Below ❑Above Iand surface Date measured � � � � WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(below land surface) �2rf ft.after � hrs.pumping r6�} g.p.m. Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION 5 i Pitless/adapter manufacturer x��t@W$tEC Model : '��Casing protection__....,_____ _____ �12 in.above grade I_�At-grade [�'Well House ��Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings.or other) � �ntanitp i� 50 3!J, Material `From To ft. Yds. �ags Matenal�atL1��To�ft ��I Yds. i�I Bags HARDNESS OF Matenal __._From To ft. ❑Yds. �,,'Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION e� cla� brawn soft Q i3 /!1 `' 4 _ j feet _direction � �type � �f Well disinfected upon completion? [�Yes ❑No �_.�..�-�. .'_=1_a:...��%.,� S�y CiB� ,)7C'IZQW 1��LlT"I 1 7 �z PUMP ua��'�7 (.'18� �ray 3�(�11�1 `l7 r+� L�Not installed Date installed ll,��lF — Manufacturer's name_ .��sC}laC�eC �_a. � �Q�t �+n �f¢ Model Number HP 1_Volts � 47ti ll Length of drop pipe__�� ft. Capacity __g.p.m �ii41�Cl.t�� ;r�y ��i�"� 5(} �j� Type:j�Submersible ❑LS.Turbine ]Reciprocating ❑Jet ❑ � ABANDONED WELLS cZay1 s�� [3y uICU1L�"� �� Ze�r poes property have any not in use and not sealed well(s)? ]Yes �No VARIANCE r.K'�R�� brflT*� �Qt� 1�U 1({(� Was a variance granted from the MDH for this well? [��.Yes No TN# WELL CONTFACTOR 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. �an Stodola tJell Dri�li s� uc�,. inc. 1591 Licensee Business Name Lic.or Reg.No. ,..:�' , �� ',l��` 11-1.�?-1.'t Certified�Representative Signature Certified Rep.No. Date � ' -; � :=: !' ; "�� tOr1o2� ---- _---- �. LOCAL COPY .• � .-- Name of Driller �: IC 740-0020 HE-01205-14�Rev.S/12) i Twin City Water Clinic taboratory Test Report Minnesota 5tate Laboretory ID#027-053-119 WiSconsin State Laborator�r�D#105-10117 Client: �on stodola well orilling Report Number: 14-i2629 Twin City Water Clinic Inc. Sample Collection Date: ii/iz/ia 617 13th Avenue South. Address: 3841 North Main street Sample Collection Time: 14:0o Hopkins,MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: ii/13/l4 PhOne: (952)935-3556 Report Issue Date: �1/�a/ia Fax:(952)935-5077 Laboreto Analyte ' Client'ID Parameter Sample Prep Sample Analysis Test Sample ID Date ' Time Date Time Results Units 14-12629 Coliform Drinking Water 11/13/14 13:07 Absent 14-12629 Nitrate/N Drinking Water 11/14/14 13:22 <3.0 mg/I 14-12629 Arsenic Drinking Water il/13/14 8:45 11/14/14 13:52 2.90 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water ' Well No.: 804571 X No samples were subcontracted;or the above test result(s) with"*'designation were produced by a subcontracted Sample pt: Well Iaboratory.,jLaboratory name;;address;MDH Lab ID#J.The Well Adr: 3160 North Shore Dr.;Orono,MN subconVacted faboratory mafntains MDH Certification for the'- Owner: Mike Waliace field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 9 'C Discussion: Notes: Approved methods used in anafyzing the samples listed above have'the following reporting levels` Maximum contaminant levels: SM9222B�Coliform,1,cfu/100 mi Coliform-<1 cfu/100 ml Nitrate Nitrogen 1i1.0'mg/I SM4500D-Nitrate Nitrogen,1.0 mg/I Arsenic,10.0 µg/i 'SM3113'B-arsenic,2A,µg/1 Lead,l5.oµg/I SM3113B-Lead,2.0µg/1 ,^ ��.��,� �� ...__ Sample Collected by: X Client _TCWC Approved By: ;, eill 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. Afl methods are certified by the Minnesota'Department of Health, unless otherwis�noted. TCWD Rev 1.2 Page 1 of 1 WELL OR RORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 2 7 9� 7 WELL AND BORING SEALING RECORD Sealing No. County Name Minnesota Unique Well No. '!@rlTl�' �il Minnesota Statutes,Cha ter 1031 or W-series No. � P �,aa�e e��k��o�k�ow,�, Township Name Township No. Range No. Section No. Fraction(sm.-�Ig.) Date Sealed . Date Well or Boring Constructed (?rono 217 23 09 S�T° � ,'�T {�� ,. GPS LOCATION- decimal degrees(to four decimal places) � �e ; Depth Before Sealing�.�__ ____ _ft. Original Depth ft ��;. Latitude __ ____ Longitude_ _ ____ �UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer Li Multiaquifer w��/ 31fi0 Nocth St�wre Dr, �ro� 55391 WELVBORING �easured ��_Estimated Date Measured�� *V-I/' �: �Water-Supply Well ',_;MoniL Well R, • % - Show exact location of well or boring r Goring � , � ��, ' in section grid with"X" location.showing operty i Ern.Bore Hole I ]Other ft. �below ,._J above land surface _....-----. _ N lines,roads,and b Idings. CASINGTYPE(S) , '-- � `- '-- � �LHEpL]Plastic '��Tile J Other teel � � _-_-- -----__. , --- - -- � �� -- � D COMPLETION : W ; ; ; ; ET _ `� � � � � Outside: ', ,Well House ��,. i At Grade Inside: ��Basement Offset '� .�°� , , , r Miie dless A p r/Unit �. 'Buried ...Well Pit � / r , , , , � �P' da te � �i. --�-- -�-- --�----�- - � � � 5 � � ��Well Pit C Buried f--i nniie—� I/�__ L/ `�� _�� _I Other __ �Other _ /if�7'��,.. G.7�� PR�O,r�PEt�RT_Y O`W.�NERyS NAME,%COMPANY NAME CASING(S) �i. L'J1A�c rr��li�(,.'� DiameIer De th � � �� j�� . p � Set in oversize hole. Annular space initially grouted. Properry owners mailing address if ditferent than well location address indicated above �C! in.from� to_��.�_ft. � ]Yes ��I No ❑Yes ll NO � f ,� �� u Unknown ; __._in.from to __ft. �_I Yes ' j Na ❑Yes ❑No U Unknown : ____,_in.from to ft. ��.. �.Yes `.J No [�,Yes L�No �_]Unknown � WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � � r r� Well owner's mailing address it ditferent than property owner's address indicated above Screen from__�,�A�_ _to ft. Open Hole from to fL ��' _ _ �_-_ _..- -. .__ OBSTRUCTIONS �]Rods/Drop Pipe � �Check Valve(s) '_1 Debris �_ .Fill �o Obstruction `: Type of Obstructions(Describe)_ ' GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? i�-1 Yes [j No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. : TYPe—____ _ J� �.Removed Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BOfiE HOLE: No Annular Space Exists '�.`]Annular Space Grouted with Tremie Pipe ��-1,Casing PerforatioNRemoval �� __ _,_ in.from_ ___ to__ _ft i_�Perforated ;J Removed ` in.from to__.. ft. �, �Perforated I.J Removed i - — Type of Perforator VARIANCE Was a variance granted from the MDH for this well? �'Yes o TN# GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � 1 t GroutingMaterial � {� f�i�,r�t�� from_ U_ __ to �� ft._____ yards�� bags -' _ from to___ ft. yards bags ' __ __ from _ to ft.___ ya�ds_ _ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on properry? I,_ ,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 Ihe best of my knowledge. 1�fitodola�t lI _��in��slc�._�4L , Licensee Business Name � License or Registration No. %`�' � ` /� � `�'- �� C �i senfa�ve SignatUre Certilied Rep.No. Date _ �� ' LOCAL COPY H - - -�� :�2 7�7 7 -- - -------- Name of Person Sealing Well or Boring HE-01434-14 IC#140-0423 .,,.. 5/13R