The URL can be used to link to this page

Home My WebLink AboutChauncy St. #75 - 6/7/2006Massachusetts Department of Environmental Management Office of Water Resources r;•0 �! - x TYPE OR PRINT ONLY Well Completion lReport oG-ai/ 1. WELL LOCATION GPS (OPYIONAL) LONGITUDE DATUM (LATITU1DE Address at Well Location:�f_47U' L'1LVd0ttp�1%GN.�4/ 7&I Property Ownedclient:__ T1,9he-_Q !� Subdivision Name: 75' ChOUt'7C _d1IR41- Mailing Address: _ y /3arlOW1_L4/Jd/7 City/Town: — N1Qngi7L d M� City/Town: POL0gsle- j MA a Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street, address available Board of Health permit obtained: Yes ❑ Not Required G Permit Number Date Issued 2. WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD BSI New Well ❑ Abandon ❑ Domestic ❑ Irrigation ❑ Cable W Auger ❑ Deepen ❑ Recondition - Monitoring ❑ Municipal ❑ Air H mer ❑ Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud er 5.:WELL LOG Water Bearing Zones Unconsolidated Consolidated 6. SITE SKETC " e n I a x n lanes) From (ft) To (ft) m = N m 2 m Other Material Rock Type Description 1 - u J� ` zQd r l "S It i e- emar�i n _.. 51ab: 7. WELL CONSTRUCTION '' 8. CASING Total Depth Drilled a-i From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Date C mple a O (o 9.SCREEN From (ft) TO (ft) Slot Size Screen Type and Material Screen Diameter T ©777 P;V' tom, N 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? El Yes °No From (ft) To (ft) Material Description Purpose Fracture -` Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ Yes ❑ No Gp 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) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 7 14. PERMANENT PUMP (IF AVAILABLE) 15.NAMEIADDRESS'OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS Sr , 17. WELL DRILLER'S STATEMENT i This well was do red, altered, and/or abandoned under my supervision, according to applicable rules and: regulations, and this report is c9mplete and correct to the best of my knowledge. " i5b Driller: Su ervising Driller Signature: � �'� r i Registration Firm: �� 7>h Date / %�� '� / [ - Rig Permit If: NOTE: Well ConrpletioelReports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY ` r n�. F3 OR PRINT Massachusetts Department of Environmental Management Office of Water Resources �/ 39�. `% k Well Completion Report !o ION GPS ( PTIONAL) LATITUDE '_ ° -OL ' Slil' LONGITUDE -. ° 1�- </ „ DATUM q d E p 6 �... M Property Owner/Client: Ad ess at Well too 'Wo / �� Sub ame: % C G Mailing Address: &0VL / City/Town: / I nshtld MA City/Town: /C191ut t {'t O/GOSH - Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required ® Permit Number_ Date Issued 2. WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD IA, New Well El Abandon ❑ Domestic ❑ Irrigation El Cable Auger N Deepen ❑ Recondition Monitoring El El Air Hammer ❑ Direct Push El Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota ❑ Other 5.:WELL LOG '.'. Water Bearing Zones Unconsolidated Consolidated 6. SITE SKETCH (use: permanent landmarks with distances) From (ft) To (ft) = y m O a m Other Material Rock Type Description A bra pix 1 ✓e- :Y L` L Weary o v 4 foe.. 7 WELL CONSTRUCTION 8. ASING Total Depth Drilled / From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Date Com lete t', r' 9. SCREEN From (it) To (ft) Slot Size Screen Type and Material Screen Diameter 16. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11.'ADDITIONAL WELL INFORMATION - Developed? ❑Yes No From (ft) To (ft) Material Description Purpose Fracture Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ Yes ❑ No i- t e - r:56/ 64 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) (hrs & 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 - - T LI 5 17. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned ,under my supervision, according to applicable e rules and regulations, and this report is complete and correct to the best of my knowledge. y Driller Z et � Supervising Driller Signature: ,' ��_ - "- Registration #: Ui"— I Firm: /A -- /..Sr .7 `r Date -r"�" _- Rig Permit #: L NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.