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HomeMy WebLinkAboutWell Record MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEATH AND BORING NO. • County Name WELL AND BORING CONSTRUCTION RECORD Ifennepin Minnesota Statutes,Chapter 1031 826669 Township Name Township No. Range No. 'Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 04 SE 07 151 1t. 11-27-17 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude s°''' Longitude ❑Cable Tool [Driven ❑Dual Rotary ❑Auger Rotary ❑Rotasonic House Number,Street Name City,and ZIP Code of Well Location r' ❑paler_, - lane* Omo 553% DRILLING FLUID r WELL HYDROFRACTURED? ❑Yes RrNo Show exact location of well/boring in section grid with"X" Sketch map of well/bor' ovation. bentonite From ft.To ft. Sh arty lines, N roads,build nd direction. USE DomesticMonitorin Au D g ❑Heating/Cooling -t ID Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial ❑Elevator Li Dewatering w F E T CASINGDrive Shoe? ❑Yes )No HOLE DIAM. MATERIAL I Threaded ❑Welded , 'h Miie ❑Steel ❑ Plastic ❑ - CASING s err fff -- Diameter * Weight Specifications �(� CI7 ( 1 nue 'rF in.To L ft. lbs/ft. in.To ++�'ft. 2017_8 .. PROPERTY OWNER'S NAME/COMPANY in.To ft. Ibs./tt. in.To""'ft. Bill Schocert8 in.To ft. lbs./ft. in.To ft.Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make From ft. To ft. same Type stainless steel Da -'1"--- ' Slot/Gauze .010 Vert* 4* Set between 143 ft.and 151 ft. FITTINGS RECEIVED �c `'�+�q STATIC WATER LEVEL " Or Below ❑Above land surface EI V G LJ Measured from} of *IIS' ate measured 'Try hole ❑Yes!�; No WELL OWNERS NAME/COMPANY NAME A D 040 ) n y� PUMPING LEVEL(below land surface 1"Ifil\ L 30�d 140 ft.after hrs.pumping g.p.m. t' WelUboring owner's mailing address if different than pro rtrtrtlll"'owner's a ress indicated above. WELLHEAD COMPLETION whi,, or Pitless/adapter manufacturer Model CITY OF ORONO D Casing protection X12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentonite., To50 ft. 3 ❑Yda, Bags Material cutting From 50 To 143 ft. ❑Yds. ❑Bags Material From To ft. GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO ❑Yds. ❑Bags MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite �p .,,,, j NEAREST KNOWN SOURCE OF CON N�N clay/wand/ '� ii 0 30 Well is 170 feet direction from 't type Well disinfected upon completion? N'Yes E No c !gravel grayindium30 52 PUMP i�� grays �rf..1r Er Not installed Date instal/44647l7 clay 52 9l Manufacturer's name Sehmeez 'radiumrecklish Model Number j HP 1 Volts sandy clay brown97 lin Length of drop pipe 105 It Capacity g.p.m. brown medium 130 44 Type Submersible Submersible ❑L.S.Turbine D Reciprocating ❑Jet ❑ ' wand ABANDONED WELLS 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,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 Sta olell Q Co. * + 1691 , Drilling Licensee Business ame• y Lic.or Reg.No. 1-17-1$ C r Representat Vii Signature Certified Rep.No. Date LOCAL COPY 826669 Name of Driller Rob Stud©la 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: 17-14365 Twin City Water Clinic Inc. Sample Collection Date: 11/27/17 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 15:30 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 11/28/17 Phone: (952)935-3556 Report Issue Date: 11/29/17 Fax:(952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 17-14365 Coliform Drinking Water 11/28/17 13:01 Absent 17-14365 Nitrate/N Drinking Water 11/28/17 13:34 <1.0 mg/L 17-14365 Arsenic Drinking Water 11/28/17 7:30 11/29/17 11:38 4.29 µg/L Lead Drinking Water µg/L mg/L Well No.: 826669 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: 3060 Fairview Lane;Orono,MN subcontracted laboratory maintains MDH Certification for the Owner: Bill Schwartz field(s)of testing performed. Owner Adr: Sample Conditions: Sample Temp: 10°C Discussion: Notes: Approved methods used in analyzing the samples listed above have the following reporting levels: Maximum contaminant levels: 5M9222B-Coliform,1 cfu/100 ml Coliform-<1 cfu/100 ml Nitrate EPA 353.2-Nitrate Nitrogen expressed as NO3+NO2,1.0 mg/L Nitrogen 10.0 mg/L Arsenic,10.0 SM3113B-Arsenic,2.0µg/I,Lead,2.0 µg/L p.g/L Lead,15.0µg/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 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 35220 2 Sealing Minnesotao W ELL AND BORING SEALING RECORD County Name Unique Well No. Minnesota Statutes,Chapter 1037 or W-series No. • .2 :i C Hennepin l -......, r' ..� .1. Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed ordliao 117. 23 04 NE SE SW /f /261/7/7 1 6 - 1 • l > 7 7 GPS LOCATION-decimal degrees(to four decimal places) / ) r_ l I Depth at Time of Sealing !/".,`7a2 ft. Original Depth / -I ;�C ft. Latitude Longitude IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer 3060 FBrvieWLane, OCOtO 55356 WLUBORING Measured Date Measured'�I7 = Mr" ❑Estimated Water-Supply Well ❑Monit.Well /y/^. Show exact location of well or boring Sketch map of, • .r boring in section grid with"X" locatio0 property ❑Env.Bore Hole ❑Other /C..., ft. Ntf below ❑above land surface N lie orfFTi;•buildings. CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other '-- f-- WELLHEAD COMPLETION W ;_._ _r__ T i__.E I Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset Mile Well Pit ❑Buried ❑Well House 1 >r/ ❑Other ❑Well Pit 7-s , F--1 Miley ❑Buried {.;n.."r.,,,._._..".. .. k,.P_.-r'.. ❑Other PRiiitiv 0 N R'S NAME/COMPANY NAME CASING(S) rtx Property owner's mailing address if different than well location address indicated above Diam eI Depth Set in oversize hole? Annular space initially grouted? f'in.from__‘) to ft. ❑Yes ❑No ['Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes El No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE /�' Well owner's mailing address if different than property owner's address indicated above Screen from / to f J Z.` ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction Type of Obstructions(Describe) HARDNESS OR GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Obstructions removed? ❑Yes ❑No Describe If not known,indicate estimated formation log from nearby well or boring. PUMP !'l/y} >f Not Present ❑Present,Removed Prior to Sealing ❑Other Type / METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE y��/!�o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing Perforation/Removal Casing Diameter in.from to ft. El 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 a 94 lbs.,one bag of bentonite=50 lbs.) t / Grouting Materialilegre l from 0 to/S-2. ` >fJ ft. yards /Z. 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? 17Yes YI 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. e ' re ati a Si;d0..". t e Certified Rep.No. Date LOCAL COPY 11352202 �-ti-._.,-. - ).---1-).---1- _.tt,-_,- -41-4--1—.......�Name of Person Sealing Well oc fforing HE-01434-15 ID#53159 8/16R