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Home My WebLink Aboutwell info MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring "�j � " � ': WELL OF BORING LOCATION Sealing No. H .? �.,� e.�r � i3 � : �o�n,Y Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, Cha ter 1031 oz W-series No. P a Olank il not known '�eru� ia �� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Construded VLa� GPS LOCATION- decimal degrees(to four decimal places) � - Depth Before Sealing ��___fl. Original Depth ft. Latitude______ Longitude_ _ AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location .Single Aquifer � �Multiaquifer ,1 559 F�,ck Lene �rQ� WELUBORING .�Measured I i Estimated Date Measured �!1/� �� Water-Supply Well [';Monit.Well � Show exact location of well or boring Sketch map of well or b ring ��Env.Bore Hole �Other _ �� ft. i�below r�above land surface in section grid with"X:' location,showing prope y - lines,roads,and buildin s. N J CASINGTYPE(S) ' ..L-- --'--- ---`-- ---t- w_ I I t i th ,'+. .] � � j ; � � � tee , as ic ( '�,Ti e �0 er . S L�P - — � '--- -' `' `-- ° � WELLHEAD COMPLETION W E � � �i __ _ __ T o� Outside: ._I Well House ��,_,At Grade Inside: �.J Basement Offse�� r g Z��5 'h M��ie �� _'Pitless Adapter/Unit �Buried �.]Well Pit 1 � _ �j Buried S nt� a� � ,_.Well Pit " ^IT/ np^� � � � ; J' _ �J Other V 1 I \_[CW Q �1 Mile—� I._Other_._______ ______ a PROPERTY OWNEF'S NAME/COMPANY NAME CASING(S) JQ� Q� Diameter � Depth � Set in oversize hole� Annular space initially qrouted? Prope«y owner's mailing address it different than well location address indicated above �� in.from to ft. I�,�Yes �No i Yes �L_I NO ❑UnknoWn -_�- _._�_ �. - .- P��• LRI�i 63� in.from_ to fL �]Yes [ j No [�Yes ��No ❑Unknown : Osseo, t�t►T 55369 : in.from_ to_..____ft. `�Yes , ;No ;.�Yes L.�i No ❑Unknown �-� WELL OWNER'S NAME,�COMPANY NAME SCREEWOPEN HOLE / / � � Well owner's mailing adoress if different than properry owners address indicated above SCfeen from�_ to�. ft. Open Hole from to ft ` OBSTRUCTIONS �l,RodslDrop Pipe ��-.Check Valve(s) (�Debris �]Fill '.]No Obstruction �.. Type of Obstructions(Describe)__ C_t��(�" ��Q��__.__ . �� GEOLOGICAL MATERIAL COLOR HARDNESS Oii FROM TO Obstructions removed? Yes � �No Describe--J��_/�^► FORMATION - PUMP If not known,indir,ate estimated formation log from nearby well or boring. Type ; i-''Removed '��✓Not Present i ,Other__, _ , a i� .. . .-__.__.-- - ---- - METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists . _Annular Space Grouted with Tremie Pipe i, 'Casing PerforatioNRemoval 3 — , in.from_._ to___ _. fc '� �Perforated __�Removed ; ___._. ___ in.trom _to__ _ tt. ',J Perforated IJ Removed Type of Perforaror VARIANCE ;' Was a variance granted from the MDH for this well? '�N ° ..,Yes o TN#_--.------ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) -. Grouting Material��,(,j� trom_�___ to��_�ft. _ yards � bags . _ . _ ._ from to ft. _ yardg _ _ _ bags _ _ _ from _ to _ ft. _ yards_____ bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DA7A,DIFfICULTIES W 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 Vue?o the best of my knowledge. �� t+Git-� 2��-t�� .� -- iL censee usin�e "�•`Ca �1� �• �cense or Regishation No. ,�': 8-12—I5 r � -- _ _- _ _ __ — _ _ Ce � p . ��r%at SignatuPe CertiliedRep.No. �Date ., " 3 3 310 9 J� :�c�on :� LOCAL COPY -- - - — --- - - - - - - _ - - -- - -- Name of Person Sealing Well or Boring \� HE-01434-14 IC#140-0423 9�3a ; WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH Seai ng No. ell and Boring I„I ��$� `�j��]� County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. �� e ' �I�� Minnesota Statutes,Chapter 1031 opaW-serieskNo. Township Name� Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ()ttxtQ 117 23 46 Nr T� S� � C,� �S GPS LOCATION- decimal degrees(to four decimal places) Q � Depih Before Sealing /� fL Original Depth ft. Latitude _ '-_ Longitude______. �IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer �]Multiaquifer . l t�r !�� Park Lane, �Q� 55356 W LVBORING �Measured [I Estimated Date Measurec��_[�7�T _ _Water-Supply Well ,.=MoniL Well / Show exact location of well or boring Sketch map of well or oring i�Env.Bore Hole �]Other_ � k. �below ,: I above land surface in sectlon grid with`X" location,showing prop rty - � lines,roads, i gs��JJJ �i N � � CASING TYPE(S) f� ��U �Steel �._'Plastic �� 'Tile _.,Other__ _ _ .-,-�C(��\/c�_ GV �G --- - � � '�� WELLHEAD COMPLETION W ; ; ; _; ET _ a � ° ' ' ' ; Outside: i._�Well House � At Grade Inside: �,.1 Basement Oftset SEP - 2015 ' � � '/Miie �� + �pitless Adapter/Unit ��. ;Buried ��1 Well Pit � : --,--- --:--- --� - :- 1 � ,_ ?` �{� 1� _ J Buried �� ' , � Well Pit C��1( OF ORON � � ' � ;Other � j Other ___ _____,___ '-. � �Mue� � — --— — — — PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) t Diam�t�f O� Dept � Set in oversize hole? Annular space initially grouted? �� Property owner s mailing a ress i difterent Ihan well location address indicated above �y in.from to_ ��__ft [�Yes �lo ��,=��Yes ��,�;No L.i Unknown ' P��• nVE C732 in.from__ �o ft. ;Ves �No ;Yes �]No �;Unknown - '�� Osseo, A�rtT 55369 '� � ' � 1 (�f� 3 _ in trom__ _ to_ _ft LJ Yes ]No []Yes ��Na _'Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � 1 t Well owner's mailing address it ditferent than property owner's address indicated above Screen from��.____._to_�__ ft. Open Hole from to ft. OBSTRUCTIONS Rods/Drop Pipe �..Check Valve(s) i ,Debris ��Fill '.J No Obstruction ' Type of Obsiructions(Descrlbe�.�i" �",�_�._G_=_ a"��/__�'P. _ . ._- _- --.. .___. 4 T GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes r'No Describe__ FORMATION PUMP r� If no known,indicate estimated formation log from nearby well or boring. `7� . �� / � TYPe._ Jv�-- �� . _ -- � ,' � �Femoved �, �,Not Pr sent [�Other_ _. ; i METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists I.:Annutar Space Grouted with Tremie Pipe _�.Casing Perforation/Removal in.from to ft. f ��perforated r Removed T_ in.from__ __ _ _to_. ___ . _.__ ._ft. �.��Perforated ��,��J Removed .,� Type of Perforator ��- _.-.-_. . __.. .._...__ �` VARIANCE Was a variance granted from the MDH for this well? !_J Yes No TN#.___ _ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) : / t :� �' Grouting Material��,��_��from .Q._. to_,�_ ft. . yards_.� bags ` E. _ -_ - _ —_ - � trom__._____ to ft. yards___ bags e =i �� from to__ .___ fl.__. yards bags ��' OTHER WELLS AND BORINGS d REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused welt 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 lo the best of my knowledge. t � Don Stod_ol� t�eell_i�cillirr; CQ, In�--15g1__ _ _-- -- ° _ _ � •_ _— Licensee Buwness lyeme ; . License or Regist�ation No. � ' ,, �'-" / .� ' '" �.' � i� /J � _ ,. . �,%`�-'f�- � � : - = - - - - - - ------ - - �d epreS''entative SignaC'ur ' Certilied Rep.No. Date .,=� .. ... S, t -�>,..,..:�.,Y1r ,. IOCAL COPY H � .J .J l� 1 L _—.- - -- - . ___-- ,- —_ __ � Name of Person Sealing Well cr B.ring — - - -------- --- - - HE-01434-14 IC#140-0423 `� 5�i3a � ��.._:-.�...._� ._,,:,, _:�,.�.�...��---=----------.�--. _.. --. � ,. -. :d,p._ . =�. .. u...�....��.��-�_:_. � �,,..-�, ,. � ,.- --"- MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �} �`7 'i WELL OR BORING LOCATION Sealing No. H ar� -� ..)�� ,.. ' County Name � WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Cha ter 7031 or W-series No. . �t'ililE� lO � p «aa�a ti��k��o,k�ow�, � Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed ' L�ciano II7 23 06 N� l� S'�° / GPS LOCATION- decimal degrees(ro four decimal places) `J � Depth Before Sealing '7� ft. Original Depth ft. Latitude________._____ Longitude .____ A�UIFER(S) - STATIC WATER LEVEL Numerical Street Address or Fire Number and City ot Well or Boring Location �Single Aquifer '�_J Multiaquifer ,�!�� /��►✓ 559 Park Lane e�'�� 5535� W uBORING �jMeasured _IEstimated DateMeasured_�I'!►�__rr_t)n7 � Water-Suppiy Well i_l Monit.Well � Show exact location of well or boring Sketch map of well or b ring � ��Env.Bore Hole � i Other__.__ 2� ft. '�below - �,above land surface in section grid with"X:' Ioc�tlon,showing prope y �� - - - - -- � � N lines,roads,and bwldin s.�� CASING TYPE(S) �.:' '--- -`- `-- `{ ,��,/ Q (� I � � j j j �;'�.' �Steel I�,Plastic � '.Tile �. ,Other _ . _ _ ,`��+�I��D � -- --- ------ ----- --- -- �� .. WELLHEAD COMPLETION �-� , � � . W ; ; ; ; E � SEP - 2015 � � � � T s �� Outside: ��i Well House ! 'At Grade Inside: � �� ___ _ __ I ]Basement Offset + 'h M�ie � � n �Buried ']Well Pit � � � .__Pitless Adapter/Unit ;:��'^ �� L]Well Pit !�Buried - �'I� OF ORON 5 � ��Other �—i M'�ie—� �`Other PROPERTY OWNTE�,R.'S NAME/CyOMPANY NAME CASING(S) J�� +�V111�Q�1 Diameter � Depth � Set in oversize hole? Annular space initially grouted? Property owners mailing address if differen�ihan well location address indicated above �� / " -- - i-� 2 in.from c�_ to_��_____ft � �Yes �No !_I Yes �_No �1 Unknown �.0. kix 532 , �� in.from __ to __,__ft �j Yes �_J No '��Yes �?No ❑Unknown . In.from to. ft. ;',Yes `�No �]Yes �J No �j Unknown � WELL OWNER'S NAME!COMPANY NAME SCREEWOPEN HOLE Well owners mailing address it different than property owner's address indicated above SCreen from_. �J r_to ��' fL Open Hole from_____ _ to _ft. OBSTRUCTIONS _j Rods/Drop Pipe ,_'Check Valve(s) �_ �.Debris i �,Fill �No Obstructlon Type of Obsiructions(Describe) ' GEOLOGICAL MATERIAL COLOR HARONESSOR FROM TO Obstructions removed? L.'�Yes i_I No Describe FORMATION PUMP If not known.indicate estimated formation log from nearby well or boring. r TYPe -— _-. .__------ ' � � �'"� �,Removed ��Not Present !]Other_ _. __ __ _ _ _____ _ ___ � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: .No Annular Space Exists [ I Annular Space Grouted with Tremie Pipe �,.i Casing Perforation/Removal �� __._______,_,__in.from__ _ to ft. ` ;Perforated �_ �Removed �� > _ _ _in.from,___ __ _.__ _to_____ ft. i 1 Perforated `]Removed �> Type of Perforator VARIANCE Was a variance graMed from the MDH for this well? i_�.Yes i No TN#__ __ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � Grouting Material��L from�r__ to_�� ft. yards..�___ bags �,- -_._-__.___.._._._--- from__, to ft. yards. --- bags ;. from___._._. to_______ ft._ yards_ _ bags �i� OTHER WELLS AND BORINGS = REMARKS,SOURCE OF DATA,DIFFICULTIES W SEALING Other unsealed and unused well or boring on property? � i 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 of my knowledge. Ikrn St«lols [�ell. Acillin�; Co,, Inc. 1691 Licensee Business me � License or Registration No. � � �: _ ,�� . �,�- l� r� , l /, n' � : .—..-- ..... __.. .—". . — — —.—_ _". —._—_—._. '_ _— r ed� resenfafive Signature ' �� Certified Rep.No. Date t, � �'�, ./,�.Rs'�c� : LOCAL COPY " 3 3 3�7 3 -__-- ----- - ---= -_ �'= Name of Person Sealing Well or Boring -- - ------------ HE-01434-14 IC#140-0423 � � 5�t3R , �z MINNESOTA UNIQUE WELL �WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. : �o��tY Na�,e WELL AND BORING CONSTRUCTION RECORD 81 O 8 9 O Minnesota Statutes,Chapter 103I ; Township Name Township No. Range No. Section No. Fraction WEWBORING DEPTH(comp�eted) DATE WORK COMPLETED A '� 11� �� QV i9aCi tri7i JCi'/ �.�� n� C�.. .� GPS LOCATION—decimal degrees(to four decimal places�. DRILLING METHOD Latitude Longitude ❑Cable Tool []Driven ❑Auger -�I Rotary House Number,Street Name.CI?y.�nd ZIP Code of Well Location �.Other '�� 559 PackI.�ane �' S5356 DPoLLWG FLUID WELL HYDROFRACTURED? JI Yes �lr�No ��.� Show exact location of well/borina i�.��.��.:-'�on grid with"X:' Sketch map of well/boring location. �r�ter From ft.To tt. �, � Showing property lines, "- roads,buildings,and direction. USE . 9 �1 Heating/Cooling ��" N �Domestic f 1 Monitorin �� _j__ , _..! __;__ �`. .;'� lj I ;Noncommunity PWS '�, �Environ.Bore Hole n Industry/Commercial . . p �^� �]Community PWS �J Irrigation [.;Remedial --- - -- ; � _ [[��Elevator �`j Dewatering ❑ A �' ; ; ' E� ! ASIN A . OLE DIAM. , � MA Drive Shoe7 �]Yes �No H " --�-----�--- --�-- --%-- �� i ! G�S �j Threaded ❑�ed , C ERI L '. , � � � ile i _ � teel , ��M � Plastic ❑ � --.--- -� 1 � :, ; - ,--- --;-- ---�- t\ � CASING : S Diameter Weight Specifications �i M�ie—� . � _._in.To 116 h. Ibs./ft. ____ �7 _in.To 5 V fl. PROPERTY OWNER'S NAME/COMPANY NAME in.To _ft. Ibs./ft. �� in.To_�GJ ft. ��n �1 T,.�_1 t _in.To _tt. Ibs./ft. __ in.To ft. tnJtltlCAl OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN ��0� 4.,.� f�n Make��__ _ . From__ ft. To ft. � �G Type�� Diam.� �s�� 75369 Slob'Gauze Length� Set between � ft.and it. FITTINGS`�t—� � STATIC WATER Measured rom � r � _��__ fl.' Below ��Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUM*PING LEVEL(below land surface) ^ 1�Q __ft.after__ G hrs.pumping___�_ _____g.pm. • Well/boring owner's mailing address if different than pioperty owner's a dress indicated above. WELLHEAD COMPLETION �iH� � ,�. � . (� ..�s„j:.c..._, � � � '�.Pitlessiadapter manufacturer�.1 t --�-��Q�-�� Model ______ ❑Casing protection __ _ _ _�12 in.above grade � ^I�O�QRCn:'`: ❑At-grade ��_1 Well House �_Hand Pump � GROUT INFORMATION(specify bentonite,cement-sand.neat-cement.concrete,cuttings,or other) Matenal_�ntO�teFrotmt_ � To_SQ ft. J �Yds. !`�Bags Material �tu�l 1_�c�nl_ .lt! To_��ft �__'.Yds. jJ�Bags HARDNESS OF Matenal __From To_ __ft ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _ _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��8y h� ai� a 5 - - __„_,�__, feet __� direction __-'""-""_'�'�+'�> _ type Well disinfected upon completion? �f Yes �_]No � �18y yella�r i� � 3i pUMP [�Not installed Date installed ��" san�y clay �ray soft 3I 44 �� _ Manufacturer's name San��•l$y �(�v �� t.). L[! .Model Number _. HP 1 aS Valts �� J 'f�f DCJ O/ Length of drop pipe_ <7'i� _____ ft. Capacity g.p.m. el�y��,ravel �r$}T (,#j,� �� C31 Type: -��Submersible ` l LS.Turbine � I Reciprocating []Jet I�._J ABANDONED WELLS �`�� ;ray �� 71, �,25 Does property have any not in use and not sealed well(s)? �J Yes .No VAAIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOA CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. oC/'� 1�/� The information contained in this report is true to the best of my knowledge. Use a second sheet,If�'Ay V - REMARKS,ELEVATION,SOURCE OF DATA,etc. �� MAY 0 y 201� � stoaola well nr�llin�__�OT. �_ 16"41— _ Licensee Business Name Lic.or Reg.No. . ' 3-3-16 4CIN OF ORONO �'- :r�_� epresentative"Si'gna u�e Certified Rep.No. Date t LOCAL COPY Q�Q Q�1�,� Name of Driller R�h �tOC�01� _" IC 140-0020 HE0120S15(Rev.8/13) � Minnesota State Laboratory ID#027-053-119 TWI11 Clt�/�/at@1' C�IIIIC �a�70PatOP�/TeSt REp01't wisconsin state�aboratory ID#to6-1o117 Wisconsin DNR Lab ID#399073400 Client: Don Stodola Well Drilling Report NumbeP: 15-11046 Twin City Water Clinic Inc. � Sample Collection Date: 09/15/15 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 15:0o Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 09/16/15 Phone: (952)935-3556 Report Issue Date: 09/17/15 Fax:(952)935-5077 Laborato Analyte Client ID Farameter Sample Prep Sample Analysis Test Sample'ID Date Time Date Time Results Units 15-11046 Coliform Drinking Water 09/16/15 14:05 Absent 15-13046 Nitrate/N Drinking Water 09/16/15 13:01 <1.0 mg/L 15-11046 Arsenic Drinking Water 09/16/15 8:30 09/17/15 13:03 2.96 µg/L Lead Drinking Water µg/L Nitrite/N Drinking Water mg/L Drinking Water Drinking Water Well No.: 810890 X No samples were subcont�acted;or the above test result(s) with'""designation were produced by a subcontracted Sample pt: Well ' laboratory. [Laboratoryname;address;MDH Lab ID#]. The Well Adr. 559 Park Lane;Orono,MN subcontracted laboretory maintains MDH Certification forthe Owner. Atlas Construction r�Hr u � � !"3 field(s)of testing performed. Owner Adr: OF ORONO Sample Conditions: Sample Temp: 14°C Discussion: Notes: Approved methods used in analyzing tt�e samples listed Maximum contaminant leveis: ' above have the#ollowing reporting levels: Coliform-z1 cfu/100 ml SM92228-Coliform,1 cfu/100 mf Nitrate Nitrogen 10.0 mg/IL SM4500E or EPA 353.2-Nitrate Nitrogen,1:O mg/L Arsenic,10.0 µg/t ' SM31136=Arsenic,2.0µg/J,Lead,2.0 µg/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: �,'�'LU/� �`'��`�'�"��'`"""� � Bill Van Arsdale Alan Senechal Laboretory 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 2.0 Page 1 of 1