Loading...
HomeMy WebLinkAboutCentral St. #335 - 5/1/2000APPLICATION FOR PERMIT TO DRILL WELL /Name 9 6 eLl 6z /e— Address 3fS �VIVq S Location Registered q n Well Driller TYPE OF WELL: omestic 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: � Domestic $ 10.00 —Industrial/Commercial $ 100.00 N/C Agricultural Date: Applicant Signature: PERMIT TO DRILL A WELL The above application has been following use at'�S and permission is granted to drill a well for the _Domestic Potable (for household use) omestic Auxiliary (for watering, pools, etc.) —industrial/Commercial Potable (for human consumption, including food processing) —Agricultural Auxiliary (for manuf g, etc.) _Agricultural (for irrigation of land in the b=f agriculture) Date: 6.0 Approved by: '/_ F r t e Board of Health NOTE. Electrical permit required; underground cable trench must be inspected Upon installation of well, call Department of Public Works office at 261-7331 to be added to well list. ELL LC Address _ Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT City/Town Well owner —. 2 oz—e Address 5 —a SO N © E W of (/eer) (cirelel N S E W of �n fem (rdrde) Board of Health permit obtained: \ye�,e no ❑ I intersect. WELL USE WELL DATA (road) Domestic ❑ Public ❑ Industria Total well depth S it, Monitoring ❑ Other ✓Y _ — Depth to bedrock 16 l 1 ft. Method drilled � lJ .� Water -bearing rock/unconsolidated material: Date drilled 7 Od Description I CASING Water -bearing zones: — Type .5 1 CG �_ f) From To Length ft. 2) From To Dia(I.D.) in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Grout ❑ Other Screen: dia. Slot# length_ ST from_ to Al IC WATER LEVEL (all walls) Static water level below land surface_,_ ft. Date�7 WELL TEST (production wells) . Drawdown 0 ft.. after pumping f!�— hr._ J min. at How measured Recovery ft. after—' hr. �. LOG of FORMATIONS aienais rrom To R ,CSC R n Driller /' GCUe 0 Firm— Address Supervising' Driller 1 Slanafurw cr q�,nn.. 7 9 91 f d lI d 111 I I BOARD OF HEALTH COPY