HomeMy WebLinkAboutFruit St. #275 - 6/21/2013Massachusetts Department of Environmental Protection
Bureau of Resource Protection
WELL DRILLER
Please specify work performed:
(Decommissioned
Please specify well type:
Monitoring
Number Of Wells:
Well Location
In public right-of-way:
r Yes !:. No]
Subdivision/Property/Description:
C- - - ---
Property Owner:
-----J
Engineering Firm:
EWROTRAC
Address at well location
Street Number:
275 �
Street Name:
[F—RUrr
Building Lot#:
Assessor's Map #:
Assessor's Lot#:
ZIP Code:
Cityffown:
MANSFIELD
GPS (GPS for the deepest well)
North: West:
142_00350171.12211
Mailing Address:
r click here if same as well location addres
Street Number: Street Name:
I2 � (MERCHANT 1
City/Town: State:
SHARON MASSACHUSETTS
ZIP Code:
02067
Board of health permit obtained:
( Yes 6 Not Required
Permit Number: Date Issued:
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Well Driller Program
Well Completion Reports(Decommission)
Well Driller - Decommission Form
WELL INFORMATION
Date Decommissioned 6i21i2013
Depth of Decommissioned Well 1 t�
ADDITIONAL INFORMATION (IF AVAILABLE)
Original WCR # for
Decommissioned Well F Well ended information type I C Overburden (_ Bedrock)
Was a new well drilled? CYe� WCR # for New Well
DEP 21 E Site # �— DEP Groundwater Discharge #
CASING
Casing Type Polyvinyl Chloride = Casing Diameter
Was casing ripped or Was Casing left in place? r Yes (. No perforated? L r Yes R Nob
Were obstructions left ----
in the well? _r Yes t: No If yes, what type? [ Choose Description
Surface Seal Type
DECOMMISSIONING MATERIAL
From To Material 1 Weight Material 2 Weight Water Batche Method Of Placement
r 1 (gal) r l
I0 11 eentonite Grout u C Choose Material Gravity
WATER LEVEL
Date Measured Static Depth BGS (ft) )Flowing Rate (gpm)
Massachusetts Department of Environmental Protection
Bureau of Resource Protection — Well Driller Program
`._ Well Completion Reports(Decommission)
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this report is complete a
knowledge.
Driller CARYCAOUETTE Registration#
Firm TECHNICAL DRILLING_, Rig Permit#
Monitoring [M] El l Supervising Dri
Date Job Con
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.