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HomeMy WebLinkAboutFruit St. #492 - 10/30/1998MANSFIELD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Address /-/ 9 eZ Hari,, � S�. Telephone 3 9 9 _ / 9S-f— Registered Well Driller Address �,s ��1 /fir 7 / E(rrf l2 k ozJ'CoY ��/ram/ -3 3 S OS- . ,�l TYPE OF WELL: Do�mestic Potable (for human consumption) vbomestic Auxiliary (for landscape 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 Date: /GApplicant The above application following use at PERMIT TO DRILL A WELL and perm�ssign is granted to drill a well for the Domestic Potable (for human consumption) �:I15omestic Auxiliary (for landscape 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. f culture) Date: Approved by:/� -- Fo th Board of Health Follow-up notes for after the well is drilled: 1. Electrical permit required, underground cable trench must bt inspected. 2. Upon installation of well, call Department of Publid Works office at 261-7331 to be added to well list 3. Display "Well Water" sign. Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT WELL LOCATION' - - 1 1 GEOGRAPHIC DESCRIPTION _ Address �% g Z FKU % S"l ' © S E W of leef) (circle) r, City/Town &S/r ' rL e <r9u Well owner 4e/yI, �1i. N, = T—/ (road) T"GcJ Address S E W of in tenths) (circle) Board of Health permit obtained; yes no ❑ intersect, w/ r` - r , ! Domestic ❑ Public ❑ Industrial ❑ Total well depth ? S r ft. Monitoring ❑ - Other_ r� Depth to bedrock Za ft. 1 Water -bearing rock/ nconsolidated material: Method drilled , �(N�<ri=tn Description Date drilled Water -bearing zones: .r CASING ) From 6 To 1 n�� S i Type J � '— / y � 2) From � rj'rf''� To "3,5'YJ r / 3) From —To Length' Cif[. Dia(LD.) G^ in. '! Length into bedrock /� r ft. Gravel pack well: dia. Protective well seal: - dia. rr Screen: Grout 2r' Other Slot# - length _ from _ to STATIC WATER LEVEL (all wells) j Static water level below land surface /O ft. Date 1 /( WELL TEST (production wells) tatr:. D tat ft. after pumping hr. min. at gpm How measured Recovery - ft. after_ hr. min. LOG of FORMATIONS COMMENTS Materials From To &4q 0d ' k v �'70 2J` Driller f Firm �fcS/J �zr�i.ii �r�f t Address Citylfown Supervising Driller Reg.# /(11/2 ' �f re o/ superviy reglsfered well driller Please print firmly ; v BOARD OF HEALTH COPY