HomeMy WebLinkAboutCarriage House Ln. #16 - 7/17/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
\,' Name
) j Address
Installer
TYPE OF WELL:
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Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
_IndustrialCommercial Potable (for human consumption, including food processing)
_IndustriaUCommercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Fee:XDomestic $ 10.00 _Industrial/Commercial $ 100.00 N/C Agricultural
Date: `% Q Applicant Signature: lid o
PERMIT TO DRILL A WELL
The above application has even approved and permis 'on is granted to drill a well for the
following use at
_Domestic Potab'- (for household use) -
_,2�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)
Date: ( C "% Approved by:
( For t oard ofIealth'
NOTE. Electrical permit required; underground ca4lei �encht ,m tstfbe inspected
46 Department of Environmental Management/Division of Water Resources
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WELL COMPLETION REPORT
WELL LOCATION
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GEOGRAPHIC DESCRIPTI%
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Address _ /r oa-r-tao
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City/Town 4r
Well owner ,/�i0 �
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Address
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Board of Health rmit obtained: --yes tom' -, no ❑
intersect. w/ � /-
WELL USE
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.WELL DATA .
Domestic Public ❑
Industrial ❑ Total well depth_:%_ ft.
Monitoring❑ Other
- Depth to bedrock ft.
Water -bearing rock/unconsolklated I
me era:
Sf A fG WA IERtEVEL (all wells)
Static water level below land su face.p2j6_ ft. Date :=
WELL TEST (production wells)
Drawdown??"q, ft. after pumping /hr.min. at
How measured �, 4 1 r Recovery C27 �; ft. after,"
LOG Of FORMATIONS I COMMENTS
DrillerD9R8S E.
Firm P.U. BOx
Address 8St f9CIONRI,
Supervising Driller
BOARD OF HEALTH COPY