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HomeMy WebLinkAboutDeer Path Lane #75 - 6/8/2001APPLICATION FOR PERMrr TO DRILL. WELL Name Address • -)�. 6�—?z - 5,AtVV - Registered � ,^_ Well Driller �BILLA, L"I s / 4' lA `r r"\12 Address I i 3 N\ f N 1 rJ ` —r (� 6 /yo o\l(L--- TYPE OF WELL: Domestic Potable (for household use) , Domestic Auxiliary (for watering, pools, etc.) _Industrial/Commercial Potable (for human consumption, including food processing) —Industrial/Commercial Auxiliary (for manufacturing, etc.) _Agricultural (for irrigation of land in the business of agriculture) Fee: -� Do 'tic S 10.0 -,_Industrial/Commerciai S 100.00 IX Agricultural Date: Z L' Applicant signature: 21z 4 PnMft11a �'"' h e The above application has byen ?a�prove e issiois and np ranted to drill a well for the following use at ' 1 71 C z I H� i L0A) Z' Domestic Potable (for household use) Domestic Auxiliary (for watering, pools, etc.) _—Industrial/Commercial Potable (for human consumption, including food processing) —Industrial/Commercial Auxiliary (for manufacturing, etc.) _,Ag ' ultural (for irrigation of land in the inss of ulture) Date: Q Approved bi�jly Forte oard of Health NOTE: Electrical permit requlred; underground cable trench ntust be inspected Upon installation ofwell, call Department of Public Forks office at 261-7331 to be added to well list 0 v 0 m O O O I r- O 52L13' .cPo A oro` CA o l yFJ� �o p006 of q Massachusetts Department of Environmental Management pt rg Office of Water Resources 0J 24 TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION G's (OPTIONAL), LATITUDE LONGITUDE Address at Well Location: Ue << r, iI�' /(,'�) '�" Property Owner: J'1 iar Subdivision Nam ` Mailing Address: City/Town: Hr a ° -F � �. i F% "' /r� CityfFown: Assessors Map Assessors Loot #% NOTE: Assessors Map and Lot # mandatory If no street address available Board of Health permit obtained: Yes LU Not Required ❑ Permit Number Aly"y Date Issued 2. ILVORK PERFORMED 3. PROPOSED USE 14. DRILLING METHOD © New Well ❑ Abandon ❑ Domestic Irrigation 1171 ❑ Cable ❑ Auger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal Air Hammer ❑ Direct Push f ❑ Replace ❑ Other Industrial ❑ Other Mud Rotary ❑ Other 5. WELL LOG ¢ Unconsolidated Consolidated 16. SITE SKETCH (use permanent landmarks with distances) H Q Permeability m v m v From (ft) To (ft) High Low - cry 8 $ Other Rock Type J 1, 7. WELL CONSTRUCTION - 6. CASING Total Depth Drilled % G From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type („ ., ^/u / w/(_!/'_ h1ex" Date Drilling Comple�eC 9. SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? 1E Yes ❑ No From (ft) To (it) Material Description Purpose Fracture Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ Yes ❑ No 12. WELL TEST DATA (PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) t, 14. PERMANENT PUMP (IF(AVAILAB ) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description /.9(_r)Y-i r��li %ii�`/off ,tiY� ` Horsepower 6 ,, j'"" Pump Intake Depth /'' ' (it) Nominal Pump Capacity (gpm) 16. COMMENTS; 17, WELL DRILLER'S STATEMENT This well was drilled 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 �? �� t upe vising Driller Signature:- (_ � 9-� '^Registration #: Ic , �7 r Firm: ' (11l t (& Z4/ 't (I ze,", Date: �� c�� RigPermit #: NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY