HomeMy WebLinkAbout Dean St. #167 - 3/15/200202/18/20D2`'1�
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10:27 FAX 508 261 7425 TOWN OF MANSFIELD
Z 002/005
M;ANSFIELD BOAS OF HEALTH
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APPLICATION F(?Yt PERFIIT'2'i7 iDRI�.Ir WELL �. 5'U � 3 3�'
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mac' i �C .�s-� r° v
Addressi OV / / eC, ._J !`Y.°L�'..lei,
Location: JC`e -r (�fr L ,,� c� S_c� � u t '% � r .5 P '✓ a � C �� ��
Registered
tell Driller: �7e4, e / < y S fir ✓� v r "C. ,-
Address. 6 .S Zc v re / / ,� 7'
TYPE OF WELL:
Dpkttostis Potable (for househoid.use)
Domestic Auxiliary (for watering, pools, etc)
Industrial/Commercial Potable (€or-humaR consumption, including food processing)
_ IndustriallCommercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land i€t.the business of agriculture)
Fee: k 17omastic Si0,04 _IndustriaUCommercial $100.00 1. Agricultural
Date: Applacaut Sigaater (. /} i ' ✓ '"
The above apple
following use at
PERMIT TO DRILL WELL .
aP�-patived and
Is granted to drill a well for the
— Domestic Potable (far householtkase)
_,.-Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (fbr human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc)
Agricultural (for irrigation of land in theLbusiness of.agi 'lcultw-e) .
Date: �� "'-Ci Approved by:
For the Board of Health
M)TO. E16cnHc41parndr mqulr4- undcrgraurul cable 1verrch mast be inspected
UPon Installation of well, call Department of Public Wop& office at
261-7331 to be added to weilfist
1
Massachusetts Department of Environmental Management p Py
Office of Water Resources 0
4985
TYPE OR PRINT ONLY Well Completion Report
Address at Well Location: 0M� l �1 .S � Property Owner: %^G1(% V^o
Subdivision Name:: / Mailing Address: ✓&
CityfTown: ,0/i/M, J t ( L 0 City/Town:
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no s(reet,address available
Board of Health permit obtained: Yes E� Not Required ❑ Permit Number Date.Essued
#
❑ New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Re lace ❑ Other
❑ Domestic 119, Irrigation
❑ Monitoring ❑ Municipal
❑ Industrial - ❑ Other
❑ Cable .: G7Auger
❑ Air Hammer 'O Direct Push
❑ Mud Rota , _: ❑ Other t
- a
m
W
Q
Permeability
High
Low
m
O
=
a
Unconsolidated
Co
cis
a
ui
a
m
Other
Consolidated
Rock Type
WM'T
m a
l�ptl�u,r
-
From (ft) To (ft)
d41
,
x tiuELt eoNSTri17?at
17
,
Total Depth Drilled
Date Drilling Complete
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
/ / j Gr/ t- / /:-' l
p
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
F
117t?D TI i
From (ft) To (ft) Material Description Purpose
Developed? es ❑ No
Fracture
Enhancement? ❑Yes I--] No
Method
Disinfected? ❑ Yes C7 No
i i. EY T� PTi'O S, n r�• n;>. t�';���;� �z k €
� T ' � X
Yield " Time Pumped Drawdown to Time Recovery to
Date Method (GPM) (hrs`& min) (Ft. BGS) (hrs & min) (Ft. BGS)
Depth Below
Date Measured Ground Surface (FT)
Iic. .��t �.�� .t,'++,.:. . "5. ��.,Gs.:2'.F'
�uV+�t� Y`�``a-`�SSisn--r�>�. S. ✓-
Pump Description ifs Horsepower_
Pumpi(ntake Depth (ft) Nominal Pump Capacity /�_ (gpm)
0a//
ane[°ato'a a
65 LAUREL ST.
3 hL „ -;" 1i51 MINT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report complete and correct to the best of my knowledge.
Driller: Ge—o 6^ (f Gar PI% dSupervising Driller Signature: h -' Registration #: A�1J
Firm: . f - / - Date: '® GJ-- 01 Rig Permit #: 3
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY