HomeMy WebLinkAbout6.k. MDH Source Water Protection Grant Application � ROSE1�l0 EXECUTIVE SUMMARY
CITY COUNCIL
City Council Meeting: September 16, 2014
AGENDA ITEM: MDH Source Water Protection Grant AGENDA SECTION:
Application Consent
PREPARED BY: Andrew J. Brotzler, PE, Director of , ic AGENDA NO. /_ �
Works / City Engineer ` V . .
ATTACHMENTS: Grant Application APPROVED BY:
RECOMMENDED ACTION: Motion to authorize the submittal of Source Water Protection
Implementation Grant Application.
ISSUE
Staff is seeking City Council approval to submit the 1�1DH Source Water Protection Implementation Grant
Application.
BACKGROUND:
Attached for City Council consideration is a Grant r�pplication with the Minnesota Department of Health
for �10,000 funding from the l�iDH. This grant is a conunuation of the grant that�vas applied for in
August, 2013 to secure funding to locate and determine the status of wells 4 and 5,which�vere abandoned
but do not have l�1DH sealing records. While Well 4 was located; the sealing status of the well has yet to
be determined. The purpose of this grant�vill be to seal Well 4 to conform to 1�linnesota Well Code. If
the�vell has not been filled with grout and the casings conform to the Minnesota Well Code, the well may
be renzrned to ser�-ice as an Obser�-ation Well in accordance�vith the Cit��'s Wellhead Protection Plan.
SUMMARY:
Staff recommends that the City Council authorize the submittal of the Minnesota Department of Health
SouYCe Water PYOtection Implementation GYant r�pplication.
G:AENGPROJ\I:NG Ufl)3-�C'ellhead Ycotectiun PIan�2013 Source AC'ater Protection Gran[\2(114091 C CC MDI{Source\C'ater Grant Application.docs
M 1 N N E S 0 T A Environmental Health Division
' Drinking Water Protedion Section
P.O. Box 64975
St. Paul, Minnesota 55164-0975
DF►AATMENToENEAITH Phone: 651-201-4700
Source Water Protection Plan Implementation Grant Application — September 2014
APPLICANT INFORMATION
Public Water Supply System: City of Rosemount PWSID: 1190019
Street Address: 2875 145ct, Street West Apartment/Unit #:
City: Rosemount County: Dakota ZIP: 55068
Name of the Person who will serve as the Grant Contact: Andy Brotzler
Phone: 651- 322-2022 Fax: 651-322-2694 Email:
a ndy.brotzler@ci.rosemou nt.m n.us
Federal Tax Id #: 41-6005501
PERSON AUTHORIZED TO SIGN APPLICATION AND GRANT AGREEMENT ON BEHALF OF THE PUBLIC WATER SUPPLIER
Name: Andy Brotzler Title: Director of Public Works
AMOUNTS
Total Cost of the Project: $ ...24,000...................
Amount Requested from MDH (minimum $1,000 maximum $10,000,or
$30,000 if 3 or more PWS-s apply jointly): $ ...10,000...................
WORK ITEM 1
For each work item to be funded under the grant, please provide the following information (use an additional page if necessary)
O Check this box if the work is a continuation from a previous MDH grant
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1. Describe the work that will be perFormed:
Seai Well 4 (Unique Well ID 212000)to conform to Minnesota Well Code. This includes services for: engineering plans and
specifications; drilling and grouting by a licensed well driller; and video inspections of the borehole as needed to seal the well. If drilling
reveals that the casing is not filled with grout, see Item 2 below.
If the work item is about managing one or more potential contaminant sources, are they located in the DWSMA? � Yes ❑ No
la. Amount Requested for performing this Work: $ 10,000
lb. Anticipated outcomes(products)of performing this work:
Well will be sealed and the MDH will issue a sealing record for this well.
1c. Please reference the MEASURE/OBJECTIVE number in the MDH source water protection approved plan (NOT the Draft Copy) or
Intake protection plan that will be supported by this work item. Attach the page(s)that contain(s)the source water protection
measure/objective;
OR
Reference the most recent SANITARY SURVEY and attach the page in that contains the action that will be supported by this work
item. (Failure to submit the required documentation may result in disqualification)
The work items are detailed in the City of Rosemount Well Head Protection Plan Part 2 dated December 2012, Objectives Al, A2, and
A4.
WORK ITEM 2
For each work item to be funded under the grant, please provide the following information (use an additional page if necessary)
O Check this box if the work is a continuation from a previous MDH grant
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2. Describe the work that will be performed:
If work performed under Work Item 1 (above) reveals that the open hole portion of the weli is not grouted and that the casings conform
to the Well Code,the well may be brought up to Code and returned to service as an Observation Well in accordance with the City's Well
Head Protection Plan. This includes services for: engineering plans and specifications; appropriate work by a licensed well driller; and
video inspections of the borehole as needed to complete the well. If the additional work reveals that the well may not be brought up to
code for an observation well, the well will be sealed per Work Item 1 above.
2a. Amount Requested for performing this Work: $10,000 (requested in Work Item 1 will be used for this task in lieu of Work Item 1)
2b. Anticipated outcomes(products) of performing this work:
Well is returned to service as an Observation Weli in accordance with the City's Well Head Protection Plan. This is a low probability
outcome but the City of Rosemount would like to retain the option to do this work should the open hole exist.
2c. Please reference the MEASURE/OBJECTIVE number in the MDH source water protection approved plan (NOT the Draft Copy) or
Intake protection plan that will be supported by this work item. Attach the page(s)that contain(s)the source water protection measure
/objective;
OR
Reference the most recent SANITARY SURVEY and attach the page in that contains the action that will be supported by this work item.
(Failure to submit the required documentation may result in disqualification)
The work items are detailed in the City of Rosemount Well Head Protection Plan Part 2 dated December 2012, Objectives A4 and G1.
WORK ITEM 3
For each work item to be funded under the grant, please provide the following information (use an additional page if necessary)
❑ Check this box if the work is a continuation from a previous MDH grant
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3. Describe the work that will be performed:
If the work item is about managing one or more potential contaminant sources, are they located in the DWSMA? ❑ Yes J No
3a. Amount Requested for performing this Work:
3b. Anticipated outcomes(products) of performing this work:
3c. Please reference the MEASURE/OBJECTIVE number in the MDH source water protection approved plan (NOT the Draft Copy) or
Intake protection plan that will be supported by this work item. Attach the page(s)that contain(s)the source water protection measure/
objective;
OR
Reference the most recent SANITARY SURVEY and attach the page in that contains the action that will be supported by this work item.
(Failure to submit the required documentation may result in disqualification)
DETAILED BUDGET AND SCHEDULE
Please describe all sub-activities that are included in the project with the corresponding costs and estimated date of completion;
use an additional page if necessary.
Sub-Activity: No of hours(where applicable): Amount: Estimated start
date:
Engineering Services— Plans, Specifications, and Record $4,400 December 2014
Drawings
Well Driller—clean out well, perforate, and grout casings $ 18,100 January 2015
Video Inspection of Well $ 1,500 January 2015
Additional estimated costs to convert to Ob Well (if feasible) $12,600
CHECKLIST
� I have attached the required documentation to my application
0 I have filled out all the fields in my application
� I have signed my application
❑ I have provided a detailed budget for each work item
❑ I have included an itemized estimate from the contractor
DISCLAIMER AND SIGNATURE
I certify that the information herein is true and accurate to the best of my knowledge and I submit this application on behalf of the
applicant public water supply system. I acknowledge that the project will be completed by June 30, 2016 and that all work performed
will be done in accordance with all Local, State and Federal Regulations:
Signature Date
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, Note: If you are awarded a grant, NO work should begin until all required signatures have been
obtained on the grant agreement, and grantee receives a signed copy of the grant agreement.
INSTRUCTIONS
You may complete this form manually or electronically. Please print the information if you opt to do this manually. Once you
are finished, you have three options for submitting the application form to the Minnesota Department of Health:
Option 1 - Mail the form to: Option 2- Fax the form to: Option 3 - E-mail the form to:
Ms. Cristina Covalschi Ms. Cristina Covalschi Cristina.Covalschi@state.mn.us
SWP Grant Coordinator SWP Grant Coordinator
Minnesota Department of Health (651) 201-4701
P.O. Box 64975
St. Paul, Minnesota 55164-0975
DEFINITIONS OF THE TERMS USED IN THIS FORM (IN THE ORDER ENCOUNTERED):
Public Water Supply System means the name that is used by the Minnesota Department of Health to identify the public
water supplier and that is associated with a public water supply system identification number.
Name of the Grant Contact means the name of the individual who will be responsible for managing the grant.
Telephone Number means the telephone number of the contact person that the Minnesota Department of Health can call
during its regular business hours(M-F from 8:30 a.m. to 4:30 p.m.).
E-mail means an internet address for the contact person that the Minnesota Department of Health can use to electronically
transmit information related to the grant.
Mailing Address means the mailing address of the Public Supply System that shall be used for correspondence with MDH.
Name and Title of the Person Authorized to Sign the Grant Agreement on Behalf of the Public Water Supply
System means a person who has authority to administer a financial agreement between the public water supplier and the
Minnesota Department of Health.
Total Grant Amount Being Requested means the sum of the costs of the work items that are identified in the grant
application (1a + 2a + 3a +....)
Work Item is the source water protection activity measure from the WHP plan that are to be performed under this part of
the grant application. Fill one box for each activity included in the project; feel free to insert more boxes if needed.
Amount requested for performing this work means the estimated amount requested by the grantee for completing
the activity performed under this part of the application.
Product(s) produced or anticipated outcomes of performing this work means the tangible results of performing
the work that is funded by this grant.
DWSMA—Drinking Water Supply Management Area; is the Minnesota Department of Health (MDH) approved surface and
subsurface area surrounding a public water supply well that completely contains the scientifically calculated wellhead
protection area.
Correspondence from MDH or Section of the sanitary survey or page number(s) in the source water protection
plan that reference the source water protection measures that will be supported by this work item—self-explanatory.
Detailed Budget means a breakdown of costs with a detailed description of all costs. Costs must be based on a written
estimate from the contractor/vendor and must be attached to the application. The total must match the dollar amount that
is being requested. The number of hours column must be filled out only for activities that involve hiring of a consultant.
Estimated start date means the date when you expect to start the work.
To request this document in a different format please call
Section Receptionist: 651-201-4700 or TTY: 651-201-5797