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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. `
County Name WELL AND BORING RECORD (� :. .
� `_s ' E. F`.. �..
�tQn�� Minnesota Statutes,Chapter 1037 C)€,j � �'t �; �;
Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED�A�
�c��t� 11 g 23 ?.f� ��' �tt%r �;�,, ��3 tt 11-5-�'a� ? ��
GPS DRILLING METHOD �` �
Latitude degrees minutes seconds y �
LOCATION: ��Cable Tool � �Driven "
Longitude degrees minutes seconds _
:�Auger �j Rotary , �
House Number,Street Name,City,and ZIP Co e of Weil Location ❑Other ' � o
i.�.�r7 �I.l3A �f�W �C� Q QTI� 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑yeF
(`�G tJ
Show exact location of well/boring in section gr+d with"X"_ Sketch map of weil/boring location. jrj�t�s[ From___ '�TD✓� __ft.
�--� —� �-5howiqg properry lines,
N � roads,buildings,and direction. USE
� ! �Domestic ❑Monitoring _ Heating/Cooling
, , , , �
�. --J--- --J--- ---L-- ---%- �., 'L,,Noncommunity PWS ❑Environ.Bore Hole n Industry/Commercial
�.. I I I I � . .
,
U --'----;--- ---`-----'— � mmu y WS iof n9 �I Remedial .
1 � �Co nit P �Irrigaf
i
� ; � � � j — k
' W � ; � E T `�� �e`� !, / CASWG MATERIALr rive Shoe? �,J Yes - No HOLE DIAM. i
�, --�--- ;----�-- ---%-- ' . / -_ D
� . — — '� � � �_]Steel ❑Threaded �_J we�ed
'hMiie T � ;�.,Plastic ❑
1 I �� 1 CASING
g ' -�� � Diameter Weight Specifications
,�
/� r�
�1 Mile� _in.To 15 5 ft. __. Ibs./ft. .i in.To�,��tt
in.To ft. IbsJft. �'� in.To���
PROPERTY OWNER'S NAME/COMPANY NAME — �—
"Ss3 rk i'; *.�l i�.�.$?'1.S '`C�<�,n;� in.To ft. IbsJft. in.To ft
Property owner's mailing address if different than well location address indicated above.
SCREEN OPEN HOLE
���' �x ,Lq Make Jah�son From ft. To ft.
,2
�:�CE�14�Qr� �r.t 7����. Type giainles� RtQP� Diam.---+-
SbUGauze__ ��1=(j Length__��,+ /,�
Set between R.and ft. FITTINGS
STATIC WATER L � EL � � �
Measured fromtt C— /�
1�� ft Below ❑Above land surface Date measured 11'�J'�1`t
WELL OWNER'S NAME/COMPANY NAME PUM�I�EVEL(below land surface) � �n
1 V
ft.after hrs.pumping g.p.m.
� Well/boring owner's mailing address i�different than property owner's address indicated above. WELLHEAD COMPLETION `
�� �Pitless/adapter manufacturer�'���.CeG1r3C£�C ___ Model 3
i Casing protection �'12 in.above grade
. ❑At-grade ❑Well House ❑Hand Pump
GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings.or other)
Material �t1rAtt��'FFrom___�_To��ft. _�_ [�Yds. �Bags ,
Material�����7 �Fibr�i�_To__���_ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Matenal From To_ ft ❑Yds. ❑Bags
MATERIAL Dnven casing seal From To __Bags
NEAREST KNOWN SOURCE OF CONTAMINATION
f11�.�CIlCt }�� C�{ :SAf� � � j '.� feet �-!...,� � .�.-,--�
___ direction ���"��^�'�'Ai"'Ty�e
Well disinfected upon completion? Yes ❑No �`'
C�.t3y t�C(Y4�1!� f�'(�ILMI °+ ��i PUMP
❑Not installed Date installed 1 i�l�"l�+`
��`�� �� fi��� '�� �� Manutacturer'sname �c��aefer
Model Number HP 1i J Volts �-n�! �
cla�Isanc� �;r � r�c?itrn !+/� Z2� - ----
r,����Z 5� Length of drop pipe ��� ft. Capacity_ g.p.m
�,,.����y� C�,,;y ; ��r*� �,p n� Type: �Submersible ❑LS.Turbine ❑Reciprocating ❑Jet �]
'� n �._c?itr�� 1,. 13>
ABA ONED WELLS
c��� b'r��� ���'t 1 3r� �t c�� Does property have any not in use and not sealed well(s)? ❑Yes No
� � � VARIANCE �
� riCI3V�1 r11,�. C�rS�a a�j r./ �(�� Was a variance granted from the MDH for this well? [�J 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.
�'�nr� :"r�;'��.a weii rri.11in„ �:�,.Tnc. lfi�2
s Licensee Busine��lne �� !• Lic.or Reg.No.
!�'_.._
�� ,/
/ ''' ��J 1-5-1.5
Certified Representative Signature Certified Aep.No. Date
, '.� �'._ ; ��, �Q.ti'} `1tC�iln�e'
i�GAL COPY � �_� � +�.,i Name of Driller
IC 140-0020 HE-01205-14(Rev.5n2)
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Minnesota State Laboratory ID#027-053-119
TWI17 CitY WBteP��1111C �dbOP8t01'y teSt R8p01't yyisconsin5tate Laboratory ID11105-101i7
Client: Don Stodola WeII,Drilling Report Number: ia-i2aso Twin City Water Clinic Inc.
Sampie Collection Date: 11/06/14 61713th Avenue South
Address: 3s41 North Main street Sample Collection Time: 15:0o Hopkins, MN 55343
st.sonifacius,MN 55375 Sample Receipt Date: ��/o�/�a Phone:(952)935-3556
Report Issue Date: ��/�o/�a Fax:(952)935-5077
Laborato Analyte ' (i�nt`ID Parameter 'Sample Prep> Sample Analysis Test
Sample tD Date Time Date Time Results Units
14-12430 Coliform Drinking Water 11/07/14 13:31 Absent
14-12430 Nitrate/N Drinking Water 11/07/14 13:35 <2.0 mg/I
1412430 Arsenic Drinking Water il/07/14 8:00 11/10/14 12:14 2.90 µg/I
Lead Drinking Water µg/I
Drinking Water
Drinking Water
Drinking Water
Well No.: 804568
�No samples were subcontracEed;or the abave test result�s)
with""designation were produc�d by a,5ubcontracted ` Sample pt: Well
laboratory.;{Laboratory name;atlltlresr,MDH Lab 1D#j.The Well Adr. 1135 Pine View Dr;Orono,MN
subcontracted laboratory maintains IVIDH Certification for the ' Owner: Mark D Williams Homes
field(s)of TesCing perFarmed.
Owner Adr:
Sample Conditions:
Sample Temperature: 7 'C
Discussion:
Notes:
Approved'methods used in analyzing thesamples
listed above have the follo ing reporting fevels: : Maximum contaminant levels;
Coliform-<1 cfu/100 ml
SM9222B-Goliform,1 cfu 100 ml Nitrate Nitrogen 10.0'rng{l
SM4500D-Nitrate Ni�rogett,I.0 mg/1 '
Arsenic,1b.0 µg/I
SM3113B-Arser�i ,2.bµg/I '
� Lead,15.0µg/I
SIN3113B=�.ead,�.(�µg/I
� �1 .+��_.
Sam le Collected b : X Client TCWC A roved B : '�_ ` "�-�
p Y _. _ PP Y �
Bill Van Arsdale Alan Senechal
Laboratory Manager Senior Analyst
The results listed in this r�port apply only to;the above listed samples.All routine quality assurance
procedures were followeid, unless otheruuise noted..This analyticel report must be reported in its entirety.:'
All methods are:certified by the Minnesota Department of Nealth, unless otherwise noted.
TCWD Rev 1.2 ' Page 1 of 1