HomeMy WebLinkAboutCobb St. #25 - 8/11/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
(age
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1n0
Address: Z S
C�
S
Telephone (SL&,S�} Z v t
t 3� 3
Location: uc 1,7 o
Registered 0 � "A ` c, L. L E `T r
Well Driller: A � W, C1 r � (� i c-, lr-L\ c��\ (" u MA Lic # 10
Address: c, L 3 c; x S q `i&0 c z.. , i s n c V r 4 4( c, z' 9 s._
TYPE OF WELL:
Domestic Potable (for household use)
L- 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
r ff }
Date: / Applicant Signature: T:;l" :;Z ,r s e
A f y t.�- s
PERMIT TO DRILL WELL
The above application has been approved and
following use at r7b e,o b b S
is granted to drill a well for the
_ 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)
Date: Approved by: S--Q4 LQ,-6— 1, �
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.
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERNIIT TO DRILL WELL
U1, f1C f
Name i Xe -Z44 - c_
Address: -,-7 ,, 0� 6, S f Telephone
Location: c3 c I 1 n an y Al G e C s Fa 1' cv j
Registered / flva vlf� fV
Well Driller: P uj f- r { Cc MA Lic # 1 C)
Address: ' 0. 'fox 549 t<e zl_ c>G.8 S
TYPE OF WELL:
Domestic Potable (for household use)
vPSomestic 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 $100.00 N/C Agricultural
d
Date: -13r1r ' o a"" Applicant Signature: ;;Z�'
f« u-,_..._
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at -?-3 b b S �-
Domestic Potable (for household use)
p,Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of land in the business of agriculture)
Date: Approved by: < _n jz( l Q
For the Board of Health
NOTE. Electrical permit required; underground cable trench must be inspected
Upon Installation of well, call Department of Public Works office at
26I-7330 to be added to well list.
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A F Or 19 ,e T <S-$ O q-�
8-5SZ.
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Massachusetts Department of Environmental Management
Office of Water Resources 4 a kj
TYPE OR PRINT ONLY - Well Completion Report
1. WELL LOeTION,. GOO (OPTIO �& LATITUDE " LONGITUDE "DATUM
Address at W` I{,ocato ( %) )� -1 � Property Owner/Client �`� /�/ (�� �J Its%l I/'7/1'� i�fi nA?
Subdivision Na'1x ' 1 fi� r'z Cr°, M, .i Mailing Address 't ? a, d„
City/Town. •", i �s 11.E °��� Cityri-own: 19 Kidd i3. 1 Ind
Assessors Map �`Assessors Lot #i NOTE: Assessors Map and Lot At mandatory if no street address available
Board of Health permit obtained: Yes ®k' r Not Required ❑ Permit Number Date Issued
2. WOR PERFORMED
3. PROPOSED USE
14. DRILLING METHOD '
[ New Well ❑ Abandon
1E--1
❑ Domestic 44..Irri6ation
❑ Cable ❑ Auger
0 Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
Q ,Air Hammer ❑ Direct Push
❑ Replace ❑ Other
Industrial ❑ Other
❑ Mud Rota ❑ Other
5. WELL LOG
Water
Bearing
Unconsolidated
Consolidated
6. SITES ETCH (use permanent landmarks with distances)
m
=
m
=
Other
Rock Typej
From (ft) To (ft)
Zones
v
N
N
m
Material
Description
tun((
r
/
aJ ,(Ja
-J
7. WELL CONSTRUCTION
8. CASING
To Depth Drilled
From (ft) To (it) Casing Type and Material Size I.D. (in) Well Seal Type
Date Complete,
;,-,�
'"���
�f 1l f r `rY'a�I
Cfy
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? ❑Yes 'No
From (it) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yes ❑-tVfo
Method
s
Disinfected? 0"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) (Ins; &
min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured
Ground Surface (FT)
r
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 abandoned under my supervision, according to applicable
rules and regulations, and this report is complete and correct to the best of my knowledge.
�,a 1 J� i
( ' �/' t �,!l< 1-��1 �Y'r L %� LL��
Driller/_(t�`Cr r �(l Supervising Driller Signature_ �� r/Ilil�� i , Registration #
6
t�.
Firm: � �' �./1 � ��`9,��f Date. ���� �'�1' ,J Ri Permit#.
NOTE: Well eovittletion Reports aarst be filed by the registered well duller within 30 days of well completion.
BOARD OF HEAL1' COPY
Massachusetts Department of Environmental Management nF-,, K" I
6
Office of Water Resources 4
Well Completion Report
TYPE OR PRINT OOLY�'
1. WELL 41OJN
[�GPS (OPTIONAL) LATITUDE LONGITUDES DATUM
Address at' ' all Lo Property Owner/Client:
Subdi ision Z Mailing Address:
kti
2,0/2-2 znz cz
City/Town: Cityrrown: /
Assessors Me 13 Assessors Lot #: NOTE: Assessors Map and Lot If mandatory if no street address available
Board of Health permit obtained: Yes FT-1--`' Not Required El Permit Number Date Issued
2. WORK PERFORMED
3. PROPOSED USE
14. DRILLING METHOD
n,-Tevv Well El Abandon
0 Domestic MI litigation
El Cable 0 Auger
El Deepen El Recondition
10
0 Monitoring El Municipal
M 16 Hammer El Direct Push
ii
El Replace 0 Other—
Industrial El Other—
0--Mud Rotary 0 Other
5. WELL LOG
Water
Bearing
B
Unconsolidated
Consolidated
6. SITE
SM121H (use pe nent 1andMarkS Math distanim;)
1 -6 11
i21
Other
Rock Type
and
I
From (ft) To (ft)
Zones
i5
N
w
15
'0
Material
Description
7. WELL CONSTRUCTION
8 CASING
71
Total Depth Drdlecll4/-)
From (ft) To (ft) Casing Type and Material Size J.D. (in) Well Seal Type
'-�
Date Complete
77 7777) 77;
9.SCREEN
From (It) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT ABANDONMENT MATERIAL
11. ADDITIONAL WELL INFORMATION
Developed? El Yes M-No
From (II) To (It) Material Description Purpose
Fracture
Enhancement? E-1 Yes M, -K0
Method
Disinfected? [0-Yes 0 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) (hrs & min) (Ft. BGS)
Date Measured
Ground Surface (FT)
&I
14. PERMANENT PUMP (IF AVAILABLE)
15. NAME/ADDRESS 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 abandoned under my supervision, according to applicable
rules and regulations, and thisre/p on is complete and correct to the best of my knowledge.
)�
.Z/ /�A) 4/
Driller /4/t Supervising Driller Signature;,,Registration #J/ 1( A I
v
Firm: 7/"", ADate. Rig Permit
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
B,DARD OF HEALTH COPY
I
1 r Massachusetts Department of Environmental Management
1 \ Office of Water Resources 17
TYPE -OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE . LONGITUDE
Well Location: -A 5 2 J Property Owner: 77 7(7- 77 7777/ 7,
Address at ,.71777) .
?//O(W 6:'0
Subdivision NamMailing Address /U
City/Town: �)�)C767,�5 �� C City/Town:i) _ �) 57 / �/6
Assessors Map Assessors Loot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes Not Required ❑ Permit Number Date Issued r "�
2. W 1K PERFORMED :
3. P1iAPOSED,USE ,`. `
A. DRILLING METHOD
New W ell ❑ Abandon
❑ Domestic 0 Irrigation
❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
❑°Air Hammer ❑ Direct Push
❑ Replace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rotaa ❑ Other
5. WELL
LOG i i
Ir
hPermeability
T
«
Unconsolidated
Consolidated,
°
5,. S1TE SKETCH (Use permanent landmarks with distances)
From (ft) To (ft)
Q
High
Low
m
C
m
N
co
m
Other
Rock Type
L
r
l�r�rkn�
7. WELL CONSTRUCTION
t
8,,CASING
Total DepthDrilled (
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
-Date Drilling Complete
0 " IG
9.SCREEN
From (ft) To (ft) Slot Size
Screen Type and Material Screen Diameter
10. FILTER PACK I GROUT ! ABANDONMENT MATERIAL
11. +ADDITIONAL WELL INFORMATION
Developed? ❑Yes Ll No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes [±1 No
Method
Disinfected? ❑ Yes ❑ No
12. WELL TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
I Depth Below
Date Method (GPM) ; (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured Ground Surface (FT)
Y"Icl
C-0
Kk-)4
30
da6
I 0)
(-2- 17
1 1
14. PERMANENT PUMP (IF;AVAII ABLE) .
16, NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
15: 'COMMENTS '
17; WELL ORILLER'S STATEMENT ..' This well was drilled and/or abandoned under my supervision, according to applicable rules
and re ulations, and this r ( rt iiss/c//o)�) lete and c�1, ct to the best of m knowledge.
��`"�C
It (6� 01
Driller: " rvi 'nggDrllle Sinnatur "" ' t �r Registration #:
%2_- 4� �� ). fl"1
Firm: _hX Date: RiPermit#:
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
i
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
701
Name
Address:
Location: 5�1n�
�// 1/dV Cf6r.5S�Na
Registered /1 [) A� `�sr��
Well Driller: O% a 7
Address:
TYPE OF WELL:
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: X Domestic $10.00 _ Industrial/Commercial $100.000/ N/C Agricultural
Date: 7 �� 64- Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved and permission is gr ted to drill a well for the
following use a G�--t W ; I I pv- �ross r
Domestic Potable (for household use)
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: d O Approved by. LJIA�(ir� n
For t e Board of HealthS7
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