HomeMy WebLinkAboutDeer Path Lane #48 - 7/29/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address It `d & Gj,,
Location
(21i /l / /--'(J bit f �W G
Address
TYPE OF WELL:
_Domestic Potable (for household use)
X Domestic Auxiliary (for watering, pools, etc.)
IndustriaUCommercial Potable (for human consumption, including food processing)
_IndustriaUCommercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
Fee: Domestic $ 10.00 _Industrial/Commercial $ 100.00 N/C Agricultural
Date: 7121`f ? Applicant Signature:
z
PERMIT TO DRILL A WELL
The above application, has ben approved nd permission is granted to drill a well for the
following use at 4 F L�? e- r,,-1,1 La "
omestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
_IndustriaUCommercial Potable (for human consumption, including food processing)
_IndustriaUCommercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: 7 -�% �_ Approved by:
For the $oard pf ITeal
NOTE: Electrical permit required, underground cabip trencll must inspected
Massachusetts Department of Conservation and Recreation
Office of Water Resources j
\TYM OR P11:31VTO 64� Well Completion Report
i\\AkELQ1dcATjON
77 7- 7 7.77 7 77 TTMquired) North77 =777 7 7 7 West
P operty Owner/Client: A s at Well ton: -A r
Su - vq-)
b ame: Mailing Address:
lo n CityfTI 0 n: — City/Town:
Assessors Map — Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes T1 Not Required 0 Permit Number — Date Issued
2. WORK PERFORMED
13. WELL TYPE 14.
DRILLING METHOD
6. CASING
2
0
Overburden
Bedrock
From (ft) To (ft) Type Thickness Diameter
1-771
LL%i
Fni
I
j
11111 E9
I Ej El El
5. WELL LOG r
OVERBURDEN
Water
Bearing
Zone
Lossor.
Addition
of Fluid
Drop in
Drill
Stem
Extra
Fast or
Slow
Drill Rate
P"
EJEJEJ
I
LITHOLOGY
7. SCREEN
From (ft) To (ft) T
ype Slot Size Diameter
From (ft) To (ft)
Code Color Comment
0
El El
1
d,)
Y / (U
-Y
F -/ T"
El El El
I .
Y N
Y N
F S
Y N
Y N
F S
8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTF
Y N
Y N
F I S
From (ft) To (it) Material Description Purpose
YIN
Y N
F / S
El El
1:1
El
Y / N
Y N
FIS
El El
El El
Y / N
Y N
FIS
El El
El El
Y / N
Y N
F / S
I Ej Ej
WELL LOG
BEDROCK
Water
Bearing
Zone
Drop in
Drill
Stem
Extra
Extra
xtra
Fast
D611 Rate
Visible
Visible
Rust
Staining
Loss or
Addition Fractures
of Fluid
#of
per foot
9. SITE SKETCH
LITHOLOGY
F91
From (ft) To (ft)
Code
Comment
---- F-1
Y f_N�
Y IC011F
/
JY
Y
i�
dd,:'
6, 11,
/0 iA
)f / h])F
/
Y
Y / �N—
Y UNI
Y /(4
F / rS
Y
Y /
Y I N
Y N
F S
Y N
Y N
Y N
Y N
F S
Y N
Y N
Y N
Y N
F1 S
Y I N
Y N
Y N
Y N
F1 S
Y I N
Y I N
Y N
Y N
F S
Y N
Y N
Y N
I Y N I
F S
Y N
Y N
I
Y NJY
NIF
SJY
NJY
N
10. WELL TEST DATA
(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
1,71,j
A-TIt',NATER LEVEL (ALL WELLS)
Yield Time Pumped
Date Method (GPM) (hrs & min)
Pumping Level Time to Recover Recovery
(Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Depth Below
Ground Surface (ft)
2,
o o,�
r;/'
12. iPERMANENT PUMP (IF AVAILABLE)
13. ADDITIONAL WELL INFORMATION
Pump Description El E] 1:1 E] Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity — (gpm)
Developed Y /QN N
Fracture Enhancement Y /� ),
Disinfected( N Surface Sea] Type IT] El 1:1
Total Well Depth Depth to Bedrock /� Y
14. COMMENTS
I
15. WELL DRILLER'S STATEMENT ]This wellwas drilled, altered, and/or abandoned under my supervision, according to applicable
rules and regulations, and this report is complete and correct to the best of my knowledge.
Driller: A Y -0 Supervising D riller Signature., Z�27m-'� -14J, Registration #J
Firm: A Date Comelete: Rig Permit #:
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY