HomeMy WebLinkAboutFruit St. #430 - 7/13/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name G Z ra � 4� (c r r
Address: � 3 O Fry i` S Telephone S-0 $ 5 J - 6
Location: S A y>� "e a S f::t �'j V�
Registered
Well Driller: , V ems,.-- bu e a 0 f r1 �� MA Lie # oq J S
) Po (�oF
Address: l SOy C k Yl k ✓
P/yr,U' i-1\ (t"Pfl s
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: Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: Applicant Signature:
PERMIT TO DRILL WELL
The above application has
following use at 9.3
and permission 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: 0 Approved by: rc ,-,
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.
24 HOUR. 2"091 ,4" AND 6" Wells
EMERGENCY
SERVICE
PUMP&WEU REPAIR
PUMPS * FILTERS * WELLS * IRRIGATION WELLS
STEVE HAMMOND 1266 BAY ROAD
781-344-8619 STOUGHTON, MA 02M
Massachusetts Department of Environmental Management
Office of Water Resources � A;l� <
TYPE OR PRINT ONLY Well Completion Report I U I n �jw
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE _° _ LONGITUDE _° DATUM
Address at Well Location: ' ���r3 > rJ / JJ-� I� Property Owner/Client: --4"A 205 e"'_
Subdivision Name: Mailing Address:
Cityrfown: City/Town: 7 f'' t -
Assessors. Map Assessors Lot If: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes ®`' Not Required ❑ Permit Number a/%: Date Issued
2. WORK PERFORMED
3. PROPOSED USE
4. DRILLING METHOD
O'"New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Replace ❑ Other
❑ Domestic Q Irrigation
❑ Monitoring ❑ Municipal
❑ Industrial ❑ Other
❑ Cable ❑ Auger
❑- Air Hammer ❑ Direct Push
❑ Mud Rotary ❑ Other
5. WELL LOG
Water
Bearing
Zones
Unconsolidated
Consolidated
6. SITE SKETCH (use Permanent landmarks with distances)
From (ft) To (ft)
w
rn
m
a
3
m
other
Material
Rock Tdype
Description
7
.- _ _. �t�� 4, •+.-�-_s �_�`__.,. _-.-----,__-
4?
K
<,J
c
�
-
V
;-2 r1
-' ', n
' i *'gym S
7. WELL CONSTRUCTION
8. CASING
Total Depth Drilled f
Date Complete
7 Z7-f"5�
From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type
1l n
S
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL
11. ADDITIONAL WELL INFORMATION
From (ft) To (ft) Material Description Purpose
Developed? 0-Yes ❑ No
Fracture ,
Enhancement? ❑ Yes F- J'No
Method /-1
Disinfected? lam' Ees ❑ No
13. STATIC WATER LEVEL (ALL WELLS)
Depth Below
Date Measured Ground Surface (FT)
12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
Yield Time Pumped Drawdown to Time to Recover Recovery to
Date Method (GPM) (his & min) (Ft. BGS) (hrs & min) (Ft. BGS)
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 rep. rt is complete and correct to the best of my knowledge.
_ 4 1 _ p
Drilier:'�) ��f2 J F-t1n,� Supervising Driller Signature: + L. ,.;e Registration #:�
,— 1 .,.. r^ C
Firm: 'date: Rig Permit If: L—L1 KrlA
NOTE: Well Completion Reports mid be filed by the registered well driller within 30 days of well completion.
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