HomeMy WebLinkAboutCedar Ridge Ln. #9 - 5/7/200376
1 51@10 wall 071__: 1
APPLICATION FOR PERMIT TO DRILL WELL
Name 1 'c- IA ( < i_--
Address:
Location: r l Cyl 0 2 0
Registered
Well Driller: �S �11� C�,��p ����%+ S
Address: (0 k, -Cat
TYPE OF WELL:
L e<-""ityk JtiL Q('t)
6 -:)X "7c
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: tDomestic $10.00 _Industrial/Commercial $100.00 N/C Agricultural
1
Date: "5 - ! -L 3 Applicant Signature:
r
PERMIT TO DRILL WELL
The above application has
following use at_ 9 1
is granted to drill a well for the
Domestic Potable (for household use)
-A.�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: O3 Approved by: S A_�=J 4Q9
For the Board of He lth
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
'APE OR PRINT ONLY
Massachusetts Department of Environmental Management 124630
Office of Water Resources
Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE
Address at Well Location: _,Z- C /`CdF-dam fie, dcX= Z/t",P operty Owner: r - % G- e/ (
C? a! -
Subdivision Name: Mailing Address: � l cl`-a7 ff i� ���-<'
City/Town: City/Town: Ad /t ads L G .,l /-n y6L-
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes E3-' Not Required ❑ Permit Number Date Issued
RMED
2. WfWell
3. PROPOSED'' USE
4. DRILLING METHOD
I-] New❑ Abandon
❑ Domestic ❑ Irrigation
❑ Cable ❑ Auger
❑ D❑ Recondition
❑ Monitoring ❑ Municipal
❑ Air Hammer ❑ Direct Push
❑ R❑ Other
❑ Industrial ❑ Other
❑ Mud Rotary ❑ Other
5. WELL LOG
Unconsolidated
Consolidated
6. SITE
SKETCH (Use permanent landmarks with distances)
W
1-7
p¢rmeability
—
w
From (ft)
To (ft)
Q
A5
=
a
N
a
v
m
Other
Rock Type
�� `w M) t'
Hlon
Low
a l,� f ,
G `� r f
7. WELL CONSTRUCTION:.
8.:CASING
Total Depth Drilled a c/
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drill' Complete
a
in
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PAC / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? [!I - Yes I--] No
From IN) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yves ❑ No
r
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. FIGS)
Date Measured Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
14u4 ' le--Y7;- 40 /-` ,j4/t
Pump Description Horsepower
f ¢ fls /�'✓�; p . max"
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
,
18. COMMENTS �GF1`�% ' `a.
lP/�-
P
17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this repogjs co p e ayd correct to the best of my knowledge.
Driller:,lU f't✓L -' upervising Driller Signature: Registration #:J
f ` ' Rig Permit #: � 'i� z � a-
Firm: � / � -� ,/ "%�� i� Date: rr
7!
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY