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HomeMy WebLinkAboutwell info a MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORDamme7 7 0 0 4 4 pin Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction ¢ WELUBORING DEPTH(completed) DATE WORK COMPLETED N4 Orow 127 23 07 $V SW, 219 12-1-M GPS LidDRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds L]Cable Tool ❑Driven ❑Dug ❑Auger :Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ J'�� 4510 Forth Shore Dr. Orow SS DRILLING FLUID WELL HYDROFRACTURED? Yes111mo Show exact location of well/boring in section grid with'X:' Sketch map of well/boring location. taj From ft.To ft. Showing property lines, roads,buildings,and direction. USE N Domestic [:1 Monitoring ❑Heating/Cooling Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �\ ❑Community PWS ❑Irrigation ❑Remedial i ------ ❑Elevator ❑Dewatering ❑ `w E T CASING MATERIAL Drive Shoe? Yes �10 HOLE DIAM. --a----------------------- 'h Mile ❑Steel ❑Threaded ❑Welded ' Plastic ❑ - -----r-----------:-- 1 CASING "`''�'•.. Diameter Weight Specifications f1Mile� �+t-�a^.: { in.to 211 ft. 1 lbs./ft. Min in.to PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to Mdgrdew/Kathy Savi 4tekJ in.to ft. lbs./ftOPEN HOLE. in.to ft. �ii+R1 Property owner's mailing address if different than well location address indicated above. SCREEN Make JobinlRorli From ft. To ft. Sam Type �•t Diam. M - Slot/Gauze n4 n Length Set between .and ft. FITTINGS STATIC WATE L Measured from ft.VBelow ❑Above land surface Date measured + WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 2W ft.atter 1.5 hrs.pumping g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer , Casing Protection 562 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted Yes ❑No Grout materials Lj Neat cement 5JBentonite Concrete ❑Other From 0 To--50ft. 4 ❑Yds. [�+Sags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To=ft. tUltUrat ffli ❑Bags MATERIAL pra"j p& From-202—To ft. ❑Yds. Bags NEAREST KNOWN SOURCE OF CONTAMINATION clay brown soft ----1,1�ao feet X / direction Well disinfected upon completion? es ❑No clayrsoft 16 4g0jPUMP / ❑Not installed Date installed S. Manufacturer's name Model Number HP_ Volts cidly/sarx! soft �+ Length of drop pipe f -7— ft. Capacity g.p.m. sandk,rayel soft 30 21 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED 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 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,it needed. - REMARKS,ELEVATION,SOURCE OF DATA,etc. Doa Stodols Well milling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. r Cal'e Signature, Certified Rep.No. Date MIN& MOM LOCAL COPY � 770044 Name of Driller IC 140-0020 -- HE-01205-11(Rev.3/07) Laboratory Test Report Engel Water Testing, Inc. 9300 County Rd. 15 * Minnetrista, MN 55359 Phone: (952) 955-1800 Fax: (952)955-1806 Minnesota State Certified Laboratory#027-003-105*Wisconsin State Certified Laboratory#105-10115 Don Stodola Well Drilling Co., Inc. 3841 North Main Street St. Bonifacius, MN 55375 Water Test Location: Report Issue Date: December 17,2009 Kathy Sawicki Year: 2009 4510 North Shore Dr. Date/Time: Sample Collection: 12/7 3:30pm Orono,MN Date/Time: Sample Recd.in Lab: 12/8 Bpm Well Unique Number: 770044 Laboratory Test Number(s): 09-7496 &09-7496A `Required when critical to the validity and application of the results Lahoratt x Ds�aCc1'f 1 TIsiB iatc T.........st 111 A3 Mctl .......;:Sam . Aul s ...:: >: Cuffs ....;:::........::::::>:. Coliform SM 9223 B 18'ED 09-7496 Bacteria 12/8 Bpm 12/9 Bpm Negative Colisure© 09-7496 Nitrate 12/9 loam 12/9 loam <1.0 mg/L Per ISE Method 3M 4500- NO3 D le ED 09-7496A **Arsenic 12/11 gam 12/15 gam <0.002 in SM 3113 B-99 Allowable Limits: ➢ Nitrate Nitrogen,mg/L: Maximum allowable limit is 10.0 mg/L or Less ➢ Coliform Bacteria: Allowable Limit is NEGATIVE ➢ Lead,mg/L:Maximum allowable limit is 0.015 mg/L or Less ➢ Arsenic,mg/L: 0.010 mg/L or Less—(0.010 mg/L or more exceeds the MDH-recommended health limit for long-term consumption of arsenic in drinking water. Subcontracted test results: ❑/No samples were subcontracted;or C� The above test result(s)with"**"designation were produced by Stearns DHIA Laboratories,825 12a`St S.,Sauk Center, MN 56378(MN Cert No.027-145-378).The subcontracted laboratory maintains MDH certification for the field(s)of testing performed. Discussion/Notes: These test results are within the allowable limits. Report authorized by: 0'* > Date: December 17, 2009 Kathryn A Engel, Laboratory birector The results listed within the report relate only to the samples received on the dates indicated. This report must not be reproduced,except in full,without the written approval from Engel Water Testing,Inc. Created by Engel Water Testing,Inc.October,2008 Page 1 of 1 BORING LOCATION MINNESOTA pEPARTMENT OF HEALTH Minnesota Well and BoringSealing I I y i'�j .,ounty Name 'i WELL AND BORING SEALING RECORD MinnesoaoUniqueWellNo. a� �jV Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank it not known) Township WirT Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed ..r 00 GPS Latitude degrees minutes____ seconds Depth Before Sealing 4Q 7 ft. Original Depth ft. LOCATION: Longitude degrees minutes_ seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /y W LLIBORING Measured [_]Estimated Date Measuredc /'`'/ Water-Supply Well ❑Monit.Well 01 Show exact location of well or boring Sketch map of well or boring- in �/) in section grid with'X" location,showing property ❑Env.Bore Hole ❑Other U.-Oft. below ❑above land surface N066 dings. CASING TYPE(S) i---------------- Steel ❑Plastic ❑Tile ❑Other ""i""""" """" """" "" T WELLHEAD COMPLETION W E I ,ti Outside: E]Well House ❑At Grade Inside: ❑Basement Offset Mlle .�� Pitless Adapter/Unit ❑Buried ❑Well Pit r 1 ❑Well Pit LJ Buried S ❑Other 1 Mile Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diem r Depth f Set in oversize hole? Annular space initially grouted? Propertyo s mai ing address rf v erent t an wel ocatlon address indicated above �- in.from to/ ft. ❑Yes No ❑Yes ❑No ❑Unknown Sam in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE /P.-7r, t r Well owner's mailing address if different than property owner's address indicated above Screen from f�r to�ft. Open Hole from t0 ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill X No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes [-]No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP Type © ❑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 Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) Grouting Meter' rom tJ917 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. Don Stodole Well Drilling Co. Inc. 1691 Licensee Business Name License or Registration No. C e entative Signat Certified-Rep.No. Date y 285100 �^ ^ LOCAL COPY H /8 5 1 O f VV 1 Name of Person Sealing Well or Boring HE-01434-11 IC#140-0423 L�VV ; j 21088