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Home My WebLink Aboutwell info • M/NNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. CountyName WELL AND BORING RECORD � �`+�} . Minnesota Statutes,Chapter 1037 �� " �� 1 Nl�T1iZ� �t3 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 4rono 217 ,, " GPS DRILLING METHOD Latitude degrees minutes seconds LOCATION: :` ��Cable Tool L_�Driven . �.Dug Longitude degrees minutes seconds I i/+uger ,�Rotary �_ ]Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �: ' ,�t�� , � . DRILLING FLUID WELL HYDROFRACTURED? '��Yes �No �}�; Show exact location of well/boring in section grid with"X:' Sketch map ot well/boring location. From ft.To ft. Showing properry lines, — — : road buildings,an irection. USE rv � � �Domestic ��Monitoring ❑Heating/Cooling � ; ; ; � .,�„�,�''��--� ' •-�+y��'4� � ' . ' 1 Noncommuniry PWS L,Environ.Bore Hole �'Industry/Commercial --'-- ---`-----` - ---'-- J �� ,�yV I_�Community PWS !�..Irrigation ❑Remedial --�--- --�------;-----�— `� �_j Elevator r;Dewatering �J �� w ; ; ; ; e T ,_,_,,._,.,. CASING MATERIAL Drive Shoe? ��Yes j�No HOLE DIAM. i__ � . --;--- --�--- --�-- ---'-- f� Threaded �.;Welded � � �Steel [] V , , , , h Mile , , , , � I;�Plastic ❑ _ � --�-- --�--- --�-- ---�- � CASING � � S � � Diameter Weight Specifications . �i M;�e—� � � in.to �� ft Ibs./ft. . _._ �//{-7n.to�ft. 2 �� in.ro ft. Ibs./ft. �4 in.to��ft. PROPERTY OWNER'S NAME/COMPANY NAME . in.to fi. Ibs./ft. in.to ft. � �� OPEN HOLE Properry owner's mailing address if different than well location address indicaled above. SCREEN .___ . Make__ �'� . From_ ft. To ft. �� ; ; 75{� t��ashic��ton Ave S TYPe stsinless st1. o�am _ _.. __ ��y(Z'c'�� J J�i�9 SIoUGauze__..�St�,L _ _Length�}t i_}__�,�.___ _ _ Set between_ ft.and ft. FITTINGS_ � w STATIC WATER LEVEL Measured from Cc��, fL[id'Below � ]Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) . �� ft.after � hrs.pumping -T� g.p.m. �� WelUboring owner's mailing address if different ihan property owner's address indicated above. WELLHEAD COMPLETION �y f�� Pitless/adapter manufacturer_Wi�1_ _ Model .._ � 'Casing Protection _ .. _____._ _ _�Q12 in.above grade '; '.l�At-grade(Environmental Well and Boring ONLY) . GROUTING WFORMATION G olu9ma eriaf's��a�aTcement �Bentonite '�oncrete I_]"bther_ � �- l'�1ttIL8t ��. �Q �7 _ — 5 To ft _ ❑Yds �L,Bags �,. HARDNESS OF From_ To ft. �Yds. �L Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ., From To ft. '�i Yds. ��;Bags NEAREST KNOWN SOURCE OF CONTAMINATION r �""'. r�� ..,�. �� t...i___feet `t.._� direction -'�---��'ty Well disinfected upon completion? es �]No ` `. PUMP r,Not installed Date installed +...,� -� � - -:a�_1 � � _ _____ $� Manufacturer's name "'3 .... Model Number HP��Volts ��' Length of drop pipe .��✓� _.ft. Capacity g.p.m. Type:l� ubmersible ��-�LS.Turbine ❑Reciprocating �,]Jet ,.J ABAN ONED WELLS . 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 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 irue to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Aoci Stodol�We11 Driltin�; Co.. Inc. 1691 Licensee Business Name - �. Lic.or Reg.No. .��'� " /�- / .-''� � �==�_ � er ed Representative Signature'� Certified Rep.No. Date LOCAL COPY f I U t.� J :� �iriC SLOC�OI.8_ — - — Name of Driller IC 140-0020 HE01205-12(Fev.12/OS) � ' Twin Cit Water Clinic Laborato Test Re Ot"t Minnesota State Laboratory ID#027-053-119 y � p Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drilling Co Report Number: ii-o5oo Twin City Water Clinic Inc. Sample Collection Date: oa/zs/si 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonffacius,MN 55375 Sample Receipt Date: oa/za/ii Phone: (952)935-3556 Report Issue Date: os/o2/ii Fax: (952)935-5077 Laborato Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 11-03634 Coliform Drinking Water 04/29/il 12:08 Absent 11-03634 Nitrate/N Drinking Water 04/29/11 12:56 <1.0 mg/I 11-03634 Arsenic Drinking Water 04/29/11 9:15 04/30/11 10:52 Q.0 µg/I Lead Drinking Water µg/I Drinking Water Drinking Water Drinking Water X No samples were subcontracted;or the above test result(s) Sample Conditions/Discussion/Notes: with'•*'designation were produced by a subcontracted laboratory. Sample Location-Well#776899 4415 North Shore Dr.Orono,MN [Laboratory name;address;MDH Lab ID#]. The subcontracted Iaboretory maintains MDH Certification for the field(s)of testing performed. Sample Temperature: 17 °C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the samples This Sample meets the listed above have the following reporting levels: Maximum contaminant leveis: State of Minnesota, Coliform-<1 cfu/100 ml SM92226-Coliform, 1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I W�sconsin and EPA SM4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic,10.0 µg/I guidelines for safe SM 3003-Arsenic,2.0µg/I �ead,15.0µg/I drinking water for the SM3113-Lead,2.0µg/I analytes tested. , �� n;'. �� .� �, - Sample Collected by: X Client _TCWC Approved By: ,,' � �� 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 I„I �'�}'� X� � County Name . WELL AND BORING SEALING RECORD Minnle90 a�Unique Well No. ' s¢ Minnesota Statutes,Cha ter 103I or W-series No. P (Leave blank il nal kn wn) Towns ip a Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � �� / c GPS Latitude degrees minutes seconds Depth Before Sealing � G.�� _ft. Original Depth _______fl. LOCATION: Longitude__ degrees minutes , seconds pQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well�or Boring Loca'tioLn ��Single Aquifer ❑Multiaquifer -��f,/y�/ A ,r1 4415 North Shoce Dr, Orano 5 J�C�! WELL/BORING i�Measure f ❑Estimated Date Measured .�Y�!►'_`i�`r Water-Supply Well [�Monit.Well Show exact location of well or boring Sketch map of well or boring �-, – , in section grid with"X." location,showing pro erty u Env.Bore Hole jJ Other �ft. [�low [;above land surtace 1 ` ines,roa and�ui s. N ,1;�:+_J.�-. ..__�._,.,�..... �,,. . CASING TYPE(S) �� ----- -------- -- --- -- � �teel ❑Plastic [j Tile ❑Other ,------------,— ; ; , � \ l� --'-----�--- ---�-----�- �y1 j t WELLNEAD COMPLETION W ; ; : . - ET ( _ _ �__ _;____; _�_ ! Outside: �]Well House ❑At Grade Inside: ❑Basement Offset '/.Miie !�Pitless AdaptedUnit ❑Buried ❑Well Pit -- - -- 1 '' � ❑Buried ❑Well Pit I S ' , ❑Other ��nniie� �Other PR ERTY NER'S[p��qM��E/COMPA N CASWG(S) .�'��r �✓�++�t� ��_$ Diame �� I Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above G� � to_�1�_fL Yes IZNO [ Yes � No in.from [� T, ] i] ❑Unknown 7544 Wa�hingtan Ave S +�d�� uct tC�43(� _ in.from to ft. ❑'Ies ❑No i]Yes _]No ��Unknown 1 !'iti 1 in.from to ft. �1 Yes ❑Na ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � Well owner's mailing address if diKerent than property owner's address indicated above SCreen hom��[O��_ft. Open Hole from to ft. OBSTRUCTIONS I�iods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill j]No Obstruction Type of Obstructions(Describe) �Jt�/t�_./� /�Tl'"'� �^ / (,J� � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? [�s ❑No Describe FOHMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �� TYPe— � � m --- A � j��. � �� Removed ❑Not Prese t ❑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___._,___,_R LJ Perforated �]Removed �� in.from to ft. ❑Perforated ❑Removed " z Type of Perforator L]Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) _ _� � A t GroutingMaterial/v'��C�,.ff/A'�` J`�Rrom� to� ft. yards�Q bags _ from to ft. yards bags ' _ ___._ irom__ 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? t LICENSED OR REGISTERED CONTRACTOR CERTIFICAT�ON 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. tk�n Stociola Well Drillic� Co„ Inc._ 1691 Licensee Business Name License or Registration No. ;�? ;:� ! ! C ed ep entative Signat Certilied Rep.No. Date �i. . � �,,�-_. LOCAL COPY H 2 914 9? ~�--� �- �^�-�.��`��-- -- Name ol Person Sealing Well or Bonng ', HE-07434-12 IC#140-0423 y si09a