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Home My WebLink AboutWell sealing record MINNESOTA UNIQUE WELL WELL 9I4430,,FtING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD • Minnesota Statutes,Chapter 1031 , 8 2 6 6 5 9 -Towns r Township No. Range No. Section No. Fraction(sm.—.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED . Orono 117 23 — 07 EX NE/ DRILLING METHOD n 10-12~47 GPS LOCATION—decimal degrees(to four decimal places). Latitude Longitude ❑Cable Tool n Driven ❑Dual Rotary 00 ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑.dN1er Pb t + � 55364DRILLING FLUID WELL HYDROFRACTURED? ❑Yes yNo Show exact location of well/boring in section grid with"X" Sketch map of wet/boring location. blt�te From ft.To ft. ' ' Showirspro lines, N roads,building3°a irection: USE /Domestic ❑Monitoring ❑Heating/Cooling IM ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commerdal ❑Community PWS ❑Irrigation ❑Remedial -- ------ - ❑Elevator ❑Dewatering ❑ w E CASING MATERIAL Drive Shoe? yrYes ❑No HOLE DIAM. Steel XThreaded ❑"Welded %Mile ❑Plastic ❑ .. 1- CASING g I Diameter * Weight Specifications 8 1 Mile 4 in.To 310 ft.- lbs./ft. in.To 50 ft. PROPERTY OWNER'S NAME/COMPAN ME in.To ft. lbs./ft. 1/4 n.To � ft. R ger in.To ft. lbs./ft. 37/8n.To ft345 . Property owner'smailing aIgi tigisits if different fh�aaalt location address indicated above. SCREEN OPEN HOLE Make From ft. Toy ft. Type Diam. Slot/Gauze Length ;- RECEIVED i Set between ft.and ft. FITTINGS r STATIC WATER LEVEL 74 IX Below ❑Above land surface >t DEC 0 LU I Measured from Date measured 1042��r Dry hole ❑Yes No i WELL OWNER'S NAME/COMPANY NAME 1 PUMPING LEVEL(below land surface) 2 y� r 230 ft.after hrs.pumping 100 g.p.m. t Well/boring owner's mailing address if different than pro�o n dlyrdskCINitdd above. W LLHEAD COMPLETION Pitless/adapter manufactur t tSr Model ❑Casing protection le12 in.above grade (. ❑At-grade ❑Well House ❑Hand Pump r GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,3concrete,cuttings,or other) Material bentonite From 0 ToNY ft. ❑Yds. Bags eS Material r ,tlfigi From__ To _ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds ❑Bags ` 'GEOLOGICAL MATERIALS COLOR FROM 'TO Dr ven casing seal From To Bagsbag= MATERIAL One 94 lbs.cement or 50 lbs.bentonite P NEAREST KNOWN SOURCE OF CONTAMINATION b id 0 /v�d W l'a"'"time Well is feet direction from j `'l' ' ' Well disinfected upon completion? A Yes E No gray imam 45 74 PUMP � 74 210 1046-47 r ❑.Not installed Date installed gray soft 210 n3 Schaefer soft 243 Manufacturer's name erit+ Model Number 1 HP _Volts 210 y lledilini 243 289 i. serdiebeyLength of drop pipe 105trwray medium 289 3436 ft. Capacity g.p.m a( e white/pink hawk 306 345 Type:$Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 7 ABANDONED WELLS '. Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE j 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Sto+f- n Drilling Cot. I . 1691 Licensee Business Name Lic.or Reg.No. if Amer' d- � ' 11 17417 if R presentativ6`Signature Certified Rep.No. Date }' LOCAL COPY 8 2 6 6 5 9 Name of Driller ID#52603 HE-01205-16(Rev.5/16) Minnesota State Laboratory ID#027-053-119 Twin City Water Clinic Laboratory Test Report Wisconsin State Laboratory ID#105-10117 Wisconsin DNR Lab ID#399073400 Client: Don Stodola Well Drilling Report Number: 17-12444 Twin City Water Clinic Inc. Sample Collection Date: 10/12/17 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 11:00 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 10/13/17 Phone:(952)935-3556 Report Issue Date: 10/16/17 Fax:(952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 17-12444 Coliform Drinking Water 10/13/17 13:16 Absent 17-12444 Nitrate/N Drinking Water 10/13/17 12:22 <1.0 mg/L 17-12444 Arsenic Drinking Water 10/13/17 8:00 10/16/17 11:54 <2.0 p.g/L Lead Drinking Water pg/L mg/L Well No.: 826659 X No samples were subcontracted;or the above test result(s) with"*'designation were produced by a subcontracted Sample pt: well laboratory. [Laboratory name;address;MDH Lab ID#]. The Well Adr: 920 Forest Arms Lane;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Roger&Theresa Meakins field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 14 'C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: SM9222B Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate EPA 3512-Nitrate Nitrogen expressed as NO3+NO2,1.0 mg/L Nitrogen 10:0 mg/L Arsenic,10.0 SM3113B-Arsenic,2.0 pg/I,Lead,2.0 µg/L tg/L Lead,15.0 ug/L EPA 353.2-Nitrite Nitrogen,1.0 mg/L Nitrite,1 mg/L Sample Collected by: X Client TCWC Approved By: Bill Van Arsdale Laboratory Manager 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 4.0 Page 1 of 1 s WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H No. ,�5 2 O V 1 CountyName WELL AND BORING SEALING RECORD MinnesotaSealie Unique Well No. Minnesota Statutes,Chapter 1031 oeW,lank nim i /4/t7' ;1 S.6 Rennean Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed Orono 117 13 97 OF g f q//7 / 1 ?- /1"77 GPS LOCATION-decimal degrees(to four decimal places) i Depth at Time of Sealing /i/e' ft. Original Depth 96 CP ft. Latitude Longitude RUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer Forest Lane, C W L/BORING Measured Date Measured 'SA/M. 1A r ❑Estimated 920 Arms La e, Orono 536 Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boringit in section rid with"X" 6 location,showing Env.Bore Hole r 9 g property ❑ ❑Other ip„7 ft. below ❑above land surface tJ �nes,roads,and buildings. ^ CASING TYPE(S) w - {{{ 1.._..{�. Steel ❑Plastic ❑Tile ❑Other WELLHEAD COMPLETION w E 1 I Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset 'h Mile ❑Well Pit ❑Buried 0 Well House _;.__.__r_ 'I 1 ❑Other ❑Well Pit Bur I---1 Mile---I ❑Other ❑Other PROPERTYl!��.. OWNER'S NAME/C0 Y NAME CASING(S) Roger $' !Tins Diam tura ! Depth Set in oversize hole? Annular space initially grouted? Property owners mailing address if different than well location address indicated above in.from Q to 92. ft. ❑Yes lo. ❑Yes ❑No ❑Unknown same ' 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 s d s Well owners mailing address if different than property owner's address indicated above Screen from 12. to 7 ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo 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 Not Present ❑Present,Removed Prior to Sealing ❑Other �i 4 Type METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal Casing Diameter in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes "No TN# GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) ' r Grouting MateriaIT�t�< from Q to 76 ft. yards e 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 Stodola well Drilling Co,. Inc. 1691 Licensee Business Name License or Registration No. ...-- � � /1- /5 / 1 C presentative gnaTure Certified Rep.No. Date LOCAL COPY H 3 5 2 081. v= . ..y Name of Person Sealing ll or Boring t HE-01434-15 IDS/53159 8/16R