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HomeMy WebLinkAboutEast St. #631 - 4/13/2006 & 6/21/2005MANSFIELD BOARD OF HEAI{T,T j APPLICATION FOR PERMIT TO DRILL V;LLP1? NameLA �d�1���7 Address:Telephone Location: O Registered Well Driller: CAJ-U4 MA Lie #� Address: TYPE OF WELL: r 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: -�L Domestic $10.00 _ Industrial/Corr Date: 41) I0Applicant Signature: PERMIT TO DRILL WELL The above application has been following use at <_ t: > � and permission is granted to drill a well for the Domestic Potable (for household use) b< .-Domestic Auxiliary (for watering, pools, etc.) Industrial/Commercial Potable (for human consumption, including food processing) Industrial/Commercial Auxiliary (for manufacturing, etc.) Agricultural (fo irrigation of land in the usmess of agriculture) Dater 07�rU(A Approved by: -- or the Board of Health NOTE. Electrical permit required, underground cable trench must be inspected Upon Installation of welC, call Department of Public Works office at 261-7330 to be added to well list: Massachusetts Department of Environmental Management �, a 4 Office of Water Resources ), TYPE OR,PfItIN 014LY = ' F` Well Completion Report 1. $L •=LOCATION P$'' TIONAL) LATITUDE ° — LONGITUDE_ "DATUM rs Add s at 1 kl-ka ioProperty Owner/Client: Sub dt `'s1�n Name t t r " Mailing- Address w� t City/To n: City/Town: AIL `i Assessor ap Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes 0{ Not Required ❑ Permit Number Date Issued 2. WORK PERFORMED 3. PROPOSED USE 4.DRILLING METHOD C `" ew Well ❑ Abandon ❑ Domestic O`Irrigation l ' Cable ❑ Auger ElDeepen ElRecondition ElMonitoring ElMunicipal ❑ Air Hammer ❑ Direct Push ❑ Replace El Other ❑Industrial El Other ❑ Mud Rotary ❑ Other 5. WELL LOG = Water Bearing Unconsolidated Consolidated 6. SITE SKETCH (Use permanent landmarks with distances) = a a Other Rock and pe From (ft) To (ft) Zones o n m Material Description ; a w wl_', I Ir' S 7. WELL CONSTRUCTION 8.'.CASING - Total Depth Drilled <' kT From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type .,� Date Complaye "„) , rr �'._r. (.� •;<::;\ t, �a t��c. fill 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? 0 Yes ❑ No From (ft) To (ft) Material Description Purpose Fracture Enhancement? ❑ Yes ❑ No Method Disinfected? U 'Yes ❑ No 12. WELL TEST DATA (ALL 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) (hrs & min) (Ft. BGS) (his & min) (Ft. BGS) Date Measured Ground Surface (FT) 14, PERMANENT PUMP (IF AVAILABLE) 15, NAME/ADDRESS OF PUMP INSTALLATION COMPANY Pump Description j,= ' i >+A', Horsepower Pump Intake Depth P i ` (ft) Nominal Pump Capacity (gpm) 16. COMMENTS 17. WELL DRILLER'S STATEMENT This well was drilled, altered, any 19'r abandoned under my supervision, according to applicable rules and regulations and this r;port is complete and correct to the best of my knowledge. Driller: Supervising Driller Signature,' i Registration Firm ` �` `�( f` <N., -t' '' ' "Date: 'nt r 1 Rig Permit#: L d l L ,� NOTE: Well Completion Repods mast be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY Massachusetts Department of Environmental Management w x OfficeofWater Resources d. ;.-• TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE _0 LONGITUDE—' — "DATUM Address at Well Location: l- �l n'i ( trN 06 < Property Owner/Client • <�� � � '' ` ` t� Subdivision Name: Mailing Address:` ` ^+,� r ' x v . . Glty%FOWn: (F � ri 9 @ d' I .� Cilty/TOWm ' i - 1/ i rl t ,-.r r r� Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot It mandatory if no street address available, Board of Health permit obtained: Yes Not Required ❑ Permit Number Date Issued` 2. WORK PERFORMED 3. PROPOSED USE 14. DRILLING METHOD © New Well ❑ Abandon ❑ Domestic P Irrigation ❑ Cable ❑ Auger Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other 0 Mud Rotary ❑ Other. S. WELL LOG Water Unconsolidated Consolidated 6. SITE SKETCH (Use Permanent landmarks with arstanoes) it Bearing m = a Other Rock and From (ft) To (ft) Zones n m Material Description From j'. I$) t 1 l c; r!cD1 q 1 _ry 4 j5E !yU 4(( k !`l tr C t r �r) 7. WELL CONSTRUCTION 8.'CASING 0, _) From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Total Depth Drilled r/\ 1 } t Date Complete 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? Q Yes ❑ No From (ft) To (ft) Material Description Purpose Fracture s Enhancement? ❑ Yes ❑ No Is Method t"" } j� Disinfected? [ Yes ❑ No 12. WELL TEST DATA (ALL 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) (his & min) (Ft. BGS) (Itrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 14. PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS 17. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abar}dbned under my supervision, according to applicable rules and regulations, and this repo is-,00�nplete and correct to the best of my knowledge. 1 / r;f' ! Registration # Driller. � >' � Supervising Driller Signatule _ U� Date -,� RigPermit #: ' ✓ s I NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion. MANSFIELD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Name Address: Telephone Telephone y �''� 1'— Location: C Registered Well Driller: . i „ _ \ MA Lic # Address: TYPE OF WELL: C� GC= < Domestic Potable (for household use) �k 0 4 / eLu 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: Domestic $10.00 _ Industrial/Commercial $100.00 N/F Agricultural Date: Applicant Signature: PERMIT TO DRILL WELL The above application has been following use at and permission is granted to drill a well for the Ji' _ Domestic Potable (for household use) b—omestic 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) Date: CP 'Z 1Approved by: W— e�,, _ For the Board of Health NOTE. Electrical permit required; underground cable trench must be inspected. Upon Installation of well, call Department of Public Works office at 261-7330 to be added to well list.