HomeMy WebLinkAboutEast St. #703 - 1/13/2006Address:
Location,• % ;
Registec�
Well Driller. -
Address: 5 3
T'YPF- OF W1 LL:
MANSFMLD BOARD OF HEALTH low n
APPLICATION FOR PERMIT TO DRILL WEI,I, & �e
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_ Domestic Potable (for household use)
I=:f1)omestic Auxiliary (for watering, pools, etc.
IndustriaUCornmerciai Potable (for human consumption, including food processing)
Industr;eJ/Commemial Auxiliary (for manufacturing, etc.)
-- Agricultural (for inrlgation of land in the business of agricu]ture)
Fee: Domestic sio.00
Date: t t
Applicant Signature:
N/C Agricultural
PERMT TO DRILY, WELL
Tire above application has been app ved d Permission is
following use at° granted to drill a well for the
�Domestic Potable (for household use)
omestic Auxiliary (for waterin
Pools.
IndustriaUCommeroial potable (for human
Industrial/Commercial Auxiliary (for �urfonsump, et, including food processing)
Date: Agricultural (for irrigation of land in the business of �cul�,e)
Date: Approved
Parthe $card of Health
NDZV; Bledr'edPermft Feguired; underground eablehench mrcwf be uespecled - —
Upon lft"OlkdOn of welly call Department ofPrrblic Works office at
26I-7330 to be a U,,ito well lisp
r
Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1 A C, , I " �' `A
4
I , v1113) 1
1. WELL LOCATION
GPS (OPTIONAL) LONGITUDE _1�10 DATUM
Address at Well Location: Property Owner/Client:
Subdivision Name: Mailing Address:
City/Town: /`4 ;,t, 1A City/Town: I,",
Assessors Map - Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes El Not Required El Permit Number =1 Date Issued
2. WORK PERFORMED
3. PROPOSED
14. DRILLING METHOD
Q-'New Well El Abandon
El Domestic El' Irrigation
Cable Auger
El
0 Deepen El Recondition
El Monitoring 0 Municipal
Air Hammer El Direct Push
JH
El Replace El Other-IE]
Industrial El Other
El Mud Rotary El Other
5. WELL LOG
Water
F ',mgel
Unconsolidated
Consolidated
6. SITE
SKETCH (use permanent landmarks with distances)
71)
Other
Rock Type
From (ft) To (ft)
-as
Material
Desand
Description
7. WELL CONSTRUCTION
8. CASING
Total Depth Drilled
From (it) To (it) Casing Type and Material Size I.D. (in) Well Seal Type
Date Complete
f �J
9.SCREEN
From (it) To (it) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT'/ ABANDONMENT MATERIAL
11. ADDITIONAL WELL INFORMATION
Developed? 0 Yes 111 No
From (ft) To (it) Material Description Purpose
Fracture
Enhancement? 1-1 Yes El No
Method
Disinfected? 0 Yes 0 No
12. WELL TEST DATA (A L SECTIONS MANDATORY FOR PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time to Recover Recovery to
Depth Below
Date Method (GPM) (hirs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE)
15. NAME/ADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth - (ft) Nominal Pump Capacity - (gpm)
16. COMMENTS 1
17. WELL DRILLERS STATEMENT This well was drilled, altered,guet6f"fitbandqued und _w- my supervision, according to applicable
rules and regulations, ands is reps # is to,1$6 best of my knowledge.
AM/
Driller: Supervising Driller Signature: Registration #J
tid
Firm; Date: Rig Permit #:
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALIN COPY