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Home My WebLink Aboutwell info WELL OR BORiNG LOCanoN MINNESOTA DEPARTMENT OF HEALTH Seai ng NoWell and Boring '„' � CountyName WELL AND BORING SEALING RECORD Minnesota Unique WeII No. Minnesota Statutes,Chapter f031 or W-series No. ��ee.-e oia�n�a m�..�> Towns ip a Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed nr 17 2.3 07 ��8 '. � GPS Latitude degrees minutes seconds + LOCATION: Depth Before Sealing ��ft. Original Depth ft. Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring location Single Aquifer ❑Multiaquifer * ELUBORING �Measured ❑Estimated �31� �Ct�l shore Dr Q� 553fi4 ater Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other � ft. �low ❑above land surface e roads,an��uuu ildmgs. N ,� ,, `` `��,�,� !',� , CASING TYPE(S) y1ti4 ��.L �Steel ❑Plastic ❑Tile ❑Other W --�- - - -;-- --i-- E WELLHEADCOMPLEIION � � � �� Outside: ❑Well House Inside: ❑Basement Otfset -;r- ---- -;-- -i-- � 1�� ❑Pitless Adapter/Unit ❑Well PR --,- -�- -�-- -i-- � "" �41 �-- � �/Jell Pit ❑Buried S �"-�'"N-�' ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter � Depth � Set in oversize hole? Annular space initially grouted? Prope owner s mai ing a ress erent tha wel ocation a dre s�in icated above (��t � � In.ffom � to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown - in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.ffOm t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAMEJCOMPANY NAME SCREEN/OPEN HOLE f + ��,(' � Well owner's mailing address rf difterent than property owners address indicated above Screen from �� t0 ��ft. Open Hole from t0 ft. OBSTRUCTIONS 1�Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Type of Obstructions(Describe)�- �� `£N�F/P �,�"T/� _"';�'f Ff'!� p �i�Xj/J HARDNESS OR �G�� GEOLOGICAL MA7ERIAL COLOR FORMATION FROM 70 Obstructions removed? Yes ❑ No Describe If not known,indicate estimated fortnation log from neaiby well or boring PUMP � ��J TYPe �� RG✓� �Cll7� �% �`Removed ❑ Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of pertorator O Other GROUTING MATERIAL(S) (One bag of cement=94�bs.,one bag of bentonite=50 Ibs.) Grouting Material �� ` ��vffrom ` ro �`� ft. yards �51 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. � I)on Stodvls �tell I�ri22i � Co., Inc. 2T172 Conhactor Business me License or Registration No. �' ,o�. /.� o� �.� present rve Si hire Date t� LOCAL COPY H Z�� T'�rl.�,,, `.,��,/�✓{1�Y�.Q.tf`t'w�-' Name o�Person Sealing Well or Boring WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I `� �'1�� County Name WELL AND BORING SEALING RECORD Mennle90 a�Unique Well No. �j `� Minnesota Statutes, Cha ter 1031 or W-series No. ?IA��: i� P ��ea�e eia�k n no�k�own� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �rnnt� 117 23 �}7 S''Q S�� ? 1� /7�A/� J ry , GPS Latitude degrees minutes seconds Depth Before Sealing_L-r� _ft. Original Depth____ .__ ft. LOCATION: Longitude degrees minutes seconds A�IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location i Single Aquifer j_]Multiaquifer ��,,�L A�r, !�315 rTorth Shnre �rs '�r�nn rTrl�'�'.�'r W �ORING Measured ]Estimated DateMeasured �' r•�= =ri _ � Water-Supply Well '�.`,MoniL Well + Show exact location of well or boring Sketch map of well or boring t � in section grid with"X" c tion,sho in property ❑Env.Bore Hole [�Other � ! ft. �below ❑above land surface ? i ,roads�n�buddings. N CASING TYPE(S) � --'--- ---'------`-- --'-- Steel ❑Plastic (J Tile �Other � --'--- --�------`-- ----- ELLHEAD COMPLETION : � W � � � � �T '''�!!`````` __.____� W • ;___,.__ __;,__.�__ --- �� ' Outside: ]Well House :j At Grade Inside: ❑Basement Offset 'hI Miie I� I�Pitless Ada ptedUnit ❑Buried ❑Well Pit I � n Buried ' ' ' ' 1 .,]Well Pit 5 �--1 Mile-� �� []Other_ ❑Other_._ _. _ PROPERTTY OW1�NER'S NAME/COMPANY NAME CASING(S) �'� +r3 a. 4+L1$(L� js�1l�s Diame/Iey� � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above L/ in.from to ft. Yes No � __ � � [� � U Yes ❑No �Unknown 15101 �tone Ridbe Trace in from_ �o ft. i ]Yes ❑No ❑Yes �f No ❑Unkr.own ��ayzata, PS�? 55391. in.from to ft. ❑Yes ❑No ❑Yes [_]No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE t /� Weli owner's mailing address if different than property owner s address indicated above SCreen from �,� to Z�(O ft. Open Hole irom to ft. OBSTRUCTIONS Rods/Drop Pipe ❑Check Valve(s) ❑Debris `Filt jJ�No Obstruction Type of Obstructions(Describe)�,l'tiN� �.Z�� ' �(/M� GEOLOGICAL MATERIAL COLOR HARDNESS OFi FROM TO Obstructions removed? Yes i� ;Na Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. n M['� Type�V 1^� �U!• 1 Y --- � �""' � ��' �Removed ❑Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,Ofi CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ;]Casing Perforation/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.) /� ,y�� ''�' / � � GroutingMaterial�/�/ CF!/��< from d to 2�� ft. yards� bags from to ft. yards bags g 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 � 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 to the best af my knowledge. �vn St�iola ?�lell I�ril l tAg�o,' Tnr. 16�1� — ; Licensee Business me s� ,y Lic nse or Registration No. '` � � T�� -s�.-��- •� �� /.� ertfied Representative Signature Certified Rep.No. Date H � � . �,�....,) _��,-`.1 lOCAL COPY �1_ � �,� `�'� �J Name ol Person Sealing Well or Boring HE-01434-13 IC#140-0423 -� si�2a , � _ � . � � � �. • ' ' MINNESOTA UNIQUE WELL WELL OR BORING LOCATION �" MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. ��. County Name WELL AND BORING RECORD 7 g 2�2 2 . ,.,�, F�erniepin Minnesota Statutes,Chapter f037 3 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED � (htmo l I7 23 Q7 ,� S't� 5�,,S Z28 n 7-8-14 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees minutes seconds ❑Cable Tool [�Driven - - — — ❑Auger ,�'Rotary House Number,Streel Name,City,and ZIP Code of Well Location Fire Number ❑Other 43I5 I�cth Shote VC� VLViIV SSJVY DRILLING FLUID 'N/ELL HYDROFRACTURED? ❑Yes � No Show exact location of welUboring in sec id with" Sketch map of well/boring location. j��e� From ft.To ft. ._�,_� Showing property lines, .. .„,�/roads,buildings,and direction. USE � N �,.�� -___ �Domestic [�Monitoring ❑Heating/Cooling . ' ' ' ' _ � u ��•�-__�� []Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial � E/� / � � ❑Community PWS ❑Irrigation ❑Remedial . � ., I I I I , --�--- --;--- --�----a-- `_/ it ❑Elevator ❑Dewatering W ; , , ; E CASING MATERIAL Drive Shoe? ❑Yes .�No HOLE DIAM. --,--- --.--- --�----.-- T .� ; `�.� ��S[eel ❑Threaded ❑Welded :�. � ; ! � Mlle / BliC ❑ _ �� l �+ Pla �; --,--- --r-- --.----.- 1 CASING S � Diameter Weight Specifications �i nniie—� _�_in.To_�Q_ft. Ibs./ft. �in.To��ft PROPERTY OWNER'S NAME/COMPANY NAME in.To____,_ __ft. Ibs./ft. �in.To�f�ft M CJ' I t�UDt� zuJli7cs in.To ft. Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. �,�t,,�� SCREEN OPEN HO�E I�tM �t� eta„� 7+C,8�� Make JVi�I ____ From ft. To ft. i�XZBt� IN�I lS�1 e Type--J��-g�� —Diam._��_ - � SIoVGauze_� Length� _� Set between ft.and ft. FITTINGS STATIC WATER L � � Measured from / � L(��__ft�Below ,�Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ��V ft.after � __ hrs.pumping g.p.m. WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer �f}Litet�tEr Model ❑Casing protection _ _ ____,_ _ �12 in.above grade � _ ❑At-grade ❑Well House � I Hand Pump � � GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) j�� Matenal-�y(I��fFrom__�To��ft. �' __ ❑Yds �Bags Matenal�a��a�€��To�ft. ❑Yds. ❑Bags HARDNESS OF Matenal___ _From To ft. ❑Yds. ]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seai From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION c2sy/cockar e�i�� itl�ll�} � YG _ yJQ feet _ �.• direction `•_yJ`"-< >,a_s--K' � C*a� � �� A � Well disinfected upon completion? �].Yes ❑No �.�5�=�:a.�.-ci+ 1 L PUMP �/8 f�t r$� ��t LQ ��C ;_�Not installed Date installed 7�(� 1 �� Manufacturer's name �:�ll�cJ.�r Model Number HP �� Volts 2.71J sarxly clay ray medi�a 23S 2I2 p Length of drop pipe_ ft. Capacity _______ g.p.m C.�� .l�� ft�f ry+�►p Type: ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 1D'L'Cil G.1G G4t7 D ABA DONED WELLS t Does property have any not in use and not sealed well(s)? (_�Yes � No VARIANCE Was a variance granted from the MDH for this well? ❑Yes '` o 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,if needed. REMARKS.ELEVATION,SOURCE OF DATA,etc. Don Stodola �iell I)rilling Ca,. Inc. 1 I Licensee Business me Lic.or Reg.No. . �� , �r r ' d pre entative�i�ature Certified Rep.No. Date � 792022 � sr«�fl�$ � LOCAL COPY -- -_—__- -- _.—_ _ Name of Driller IC 140-0020 � HE-01205-13(Rev.11/10) a �. ~ Minnesota State Laboratory ID#027-053-119 Twin City 11Vater Clinic Laboratory Test Report Wisconsin State Laboratory ID#105-10117 Client: Don Stodola WeII Drilling Co Report Number: ia-ma�z Twin City Water Clinic Inc. Sample Collection Date: o�/os/ia 61713th Avenue South Address: 3841 North Main Street Sample Collection Time: ie:oo Hopkins,MN 55343 st.sontfac�us,MN 55375 Sample Receipt Date: 0�/o9/ia Phone:(952)935-3556 Report Issue Date: o�/io/la Fax:(952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 14-07372 Coliform Drinking Water 07J09/14 13:36 Absent 14-07372 Nitrate/N Drinking Water 07/09/14 13:49 <1.0 mg/I 14-07372 Arsenic Drinking Water 07/09/14 8:30 07/10/14 13:11 62.90 µg/I Lead Drinking Water µg/I Drinking Water Drinki�g Water Drinking Water Well No.: x No samples were subcontracted;or the above test result(s) ' with""*'designation were produced by a subcontracted Sample pt: laboretory. [Laboretory name;address;MDH Lab ID#].The Well Adr: 4315 No Shore Dr.Orono,MN, subcontracted laboretory maintains MDH Certification for the Owner: M51 Custom Homes field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temperature: 8 °C Discussion: Notes: Approved methods used in anaiyzing tne samples listed above have the following reporting levels: Maximum contaminant Ieveis: SM9222B-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrafe Nitrogen,1.0 mg/I Arsenic,10.0 µg/I SM3113B-Arsenic,2.0µg/I Lead,15.0µg%I SM3113B-Lead,2.0µg/I 1 ' ! I . �al.%�T,� Sam le Collected b : X Client TCWC A roved B : � �� p Y — — pP Y �r Bill Van Arsdale Alan Senechal LaboratoryManager SeniorAnalyst • The resuits listed in this report apply only to the above listed samples.All routine quality assurance procedures were foliowed, 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