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HomeMy WebLinkAboutFruit St. #265 - 8/5/2008APPLICATION FOR PERMIT TO DRILL WELL Name Address: ,� � S ��( zf i `?� � Telephone ✓�,0 � ' Location: ✓,g.#sT-L�1//i Registered /� Well Driller: fy 11 Z"A r'r MA Lic # Address: , Its2M,,3i�>> 1z. /(`F Games C TYPE OF WELL: 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.) gricu)(fnr irria_ oatin� f land in *1+.._ ? ,.._:nggg,gfggriculture) Fee: lestic $10.00 Date: The above application has following use at ,27— ( Industrial/Commercial $100.00 N/C Agricultural Applicant Signature: and permission is granted to drill a well for the Domestic Potable (for household use) mestic 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 busin of agriculture) Date: � k Approve&by`� or 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 TYPE OR PRINT ONLY Massachusetts Department of Environmental Management Office of Water Resources Well Completion Report TM 3 1. WELL LOCATION, GPS (OPTIONAL) LATITUDE LONGITUDE° DATUM Address at Well Location: 3 r Property Owner/ry,.I'tent d A r i i'' f:G Lam- ski r/" 1 r•? Subdivision. Np ie " -' 1, `l - $ Mailing Address d 10 ZIP)"' "Y/ : k� � �� '_ > i i �• � d i d(, t' Add �, d4 � C � �� Bit own: Z- � CityRown. . Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required O' - Permit Number Date Issued 2.1110 K PERFORMED `" 3. PROPOSED USE 4. DRILLING' METHOD ®"New Well ❑ Abandon ❑ Domestic ❑ Irrigation ❑ Cable E!I uger ❑ Deepen ❑ Recondition ❑"`Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rotary ❑ Other 5. WELL LOG Water Bearing Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks withrafstances) m = m a Other Rock Type ' From (ft) To (ft) zones o N rn cr m Material Description i S 9 S.1 r i # 7.`WELL CONSTRUCTION 8.iCASING Total Depth Drilled 49 "t From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Date Complete,I 'i t,3 ( _ ° � aF ?r v 9. SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter a p �t d i_ <..1 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? El Yes Evwi From (ft) To (ft) Material Description Purpose Fracture ^` t t $ r",,�3 a a Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ 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) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date M asured Ground Surface (FT) 14. PERMANENT PUMP (IFAVAILABLE)15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) `; Nominal Pump Capacity (gpm) 16. COMMENTS .- ,._�!_.:z`f ,,'LIj P a1 . 17. WELL DRILLER'S STATEMENT - This well was drilled, altered and/gY,.'aban55i'' ned yjliier; y so rvision, according to applicable rules and regulations, and tftis repoft is c¢1iplet¢�and/correct to the best of my kn9wledge Drillergg� Supervising Driller Signatute��/' /,,r ��- --'Registration # Firm: 148 pioneer Drive � Date. 6- / r '60 Leommu i m4lew4a,s must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY Massachusetts Department of Conservation and Recreation Office of Water Resources m TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (Required) North . — West— u.,,,. r r A,� Address at Well location. % ^ e `�� Property Owner/Client A�' ,:= Subdivision Name:Mailing Address: Cit!Gown "i`l e�`� City/Town: MA' c a Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot It mandatory if no street address'p vaP able Board of Health permit obtained: Yes El' Not Required ❑ Permit Number Date Issued 2.''WORK PERFORMED' 3. WELL TYPE 4.:DRILLING METHOD 6.:CASING jaitz �.�p"�g���yr Overburden I Bedrock From (it) To (ft) Type Thickness Diameter ''fi`%:6 Qfi>fa'. .::y. y r El ❑ ❑ 6,,,.'' .�} Ff• +t—'ILJ� Ej 5. WELL LOG OVERBURDEN Water Bearing Zone Loss or Addition of Fluid Y/ N Drop in Drill - Stem Y/ N Extra Fast or Slow Drill Rate F/ S ❑ ❑ ❑ LITHOLOGY 7. SCREEN - From (ft) ;To (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment s" -iP' E<t 4.„,,, e° CIJ tY / N Y / N � (F3/ S ❑ ❑ ❑ — — — 20 rs%.__a z(.1 -,n� �Y)/ N Yi/ N �F./ S -❑ ❑ ❑ Y / N Y / N F / S B, ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL' Y / N Y / N F / S = From (ft) To (It) Material Description Purpose Y/N Y/N F/S' z Is 1 m.�.. Y/N Y/N F/'S- ❑❑ El El Y / N Y / N F / St, ❑ ❑ ❑ ❑ Y/N Y/N F/`S ❑❑ ❑❑ WELL LOG BEDROCK Water Bearing Zone Drop in Drill Stem Extra Large Chips. Extra Fast or Slow Dnll Rate Visible Rust Staining Loss or Addition Fractures!�r' of Fluid Hof per foot 9. SITE SKETCH _ LITHOLOGY ^' r$a u rr L-r- l'3`° < I t� a� �_-Q-' d �F From (ft) To (ft) Code Comment Y/NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y/NYIN F/S Y/N Y/N� Y/>NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y/NY/N SJY Y/N Y/N Y/ N F/ S Y/ N Y/ N N Y/ F/S Y/N Y/NY/N 1N1 Y/N F/S Y/N Y/ N F/ S Y/ N Y/ N) 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATER LEVEL (ALLSWELLS Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below Date Metbod) (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (ft) --­ ? d"D �,'�S"•" n ar , 12. PERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION 2 El Q 0 "' Pump Description Horsepower�� Develo e Y/ N Fracture Enhancement Y�/€N- P Pump Intake Depth (ft) Nominal Pump Capacity dRd2 "m (gpm) Disinfectec( YF / N Surface Seal Type 11 _ , ,)/�?1', Total Well Depth €- _ =v Depth to Bedrock 14. COMMENTS i� : t -€� €t� _� �,' �) 15:'WELL DRILLER'SSTATEMENT ___` This well was drilled, altered, and/or.abandoped under my supervision, according to applicable rules and regulations and tots iepQ&is complete'and correct to the best of my knowledge.. v ,. € 6 ar � s` � � ` €"a i, - t �r �- # r' � `� � � Driller � � � v,- � Supervising Driller Signature��� � � Registration � � � g j f `., , �s` "d.„tr ,.,, a, A:.,7a'��f .i• rys ✓ Yi = %.'': RigPermit If: Date Complete: Firm: :# NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY � TYPE OR PRINT ONLY Massachusetts Department of Conservation and Recreation Office of Water Resources Arg � 1 1-7 01 Well Completion Report 1. WELL LOCATION ° — . GPS (Required) North 7q7 "- O _. 0— West/77- Address at Well Location:// Property Owner/Client: J S o Subdivision Name: Mailing Address: Ig CityfFown: Q2r City/Town: ` Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required VI Permit Number Date Issued 2.'WORK PERFORMED to 5. WELL LOG °' 3. WELL TYPE • of OVERBURDEN 4. DRILLING METHOD " Overburden Bedrock ®o0 00 Extra Water Loss or DIDrill , Fast or, Bearing` Addition Drill Slow zone of Fluid Stem Drill Rate Y / N Y / N F / S 6. CASING From (ft) To (ft) ,Type Thickness Diameter �- ®� 0 1, ❑❑ ^,'I ❑ ❑ ❑ LITHOLOGY, �. . 7' SCREEN From (ft) -To (ft) Type .,Slot Size Diameter From (ft) To (ft) Code Color Comment ❑ ❑ El . — — — Y / N Y / N F / S { Y / N Y / N F / S g. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL Y / N Y / N F I S From (ft) To (ft) Material Description Purpose Y/ N Y/ N F/ Sn a]a Y/N Y/N F/Sz El El ❑❑ Y/ N Y/ N F/ S El El El El WELL LOG ' - BEDROCK Water Bearing Zone Y / Drop in Drill Stem N Y Extra Large Chips / N Extra Fast orSlow Drill w F/'S... Visible Rust Staining Loss or Addition Fractures of Fluid N of per foot ❑ ❑ ❑ ❑ 9.-SITE SKETCH; LITHOLOGY From (ft) To (ft) Cdde Comment; Y/NY/NFlSY/NY/N Q 1�, „� McAls iab%�IILe Y/N Y/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y l N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N F/ S F/ S Y/ N Y/ N Y/ N Y/ N YIN Y/N F/S Y/N Y/N ' Y/NY/NF/SY/NY/N Y/NY/N F/S Y/N Y/N Y/NY/NF/SY/NY/N 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATER LEVEL (ALL i WELLS) Yield Time Pumped Date Method (GPM) (hrs & min) Pumping Level Time to Recover Recovery (Ft. BGS) (firs & min) (Ft. BGS) Date Measured Depth Below Ground Surface (ft) 0131 12.'PERMANENT PUMP (IF AVAILABLE) 113. ADDITIONAL WELL INFORMATION Pump Description 1101111 Horsepower Developed Y / N ; Fracture Enhancement Y / N Pump Intake Depth _� "� - (ft) Nominal Pump Capacity (gpm) Disinfected Y / N Surface Seal Type ❑ 169 14. COMMENTS �.1i' �, Total Well Depth ZV / Depth to Bedrock 15.+WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision, according to applicable i1 ,� r _-rules and regulations, and thi repo /is.corpplete aqq'ii,correct to the best of my knowledge. Driller ' T i" f °/'/ Supervising Ddller Signature: �r s) - � Registration #: � Firm: Date Complete: �'� , ` a *' Rig.Pq'rrnt NOTE: Well Completion Reports nmst be filed by the registered wellidriller within 30 days of well completion. BOARD OF HEALTH COPY Massachusetts Department of Conservation and Recreation Office of Water Resources TYPE -OR, .PRINT ONLY Well Completion Report WELL LOCATION c GPS (Required) North o O 0. -D- West /--° . Address at Well Location: AldProperty Owner/Client: / Subdivision Name: A 'lAlf Mailing Address: 44 41 City/Town: /%Ui1C!/iuu / A— Cityffown: �' Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required DO Permit Number Date Issued 2. WORK PERFORMED 13. WELL TYPE 4. DRILLING METHOD 6. CASING OOvverburden Bedrock From (ft) To (M Type Thickness Diameter .LVJ ❑ ❑ o c ❑❑❑ 5.WELL LOG OVERBURDEN Water Bearing Zone Loss or Addition of Fluid Y/N Drop in Drill Stem Y/N Extra Fast or Slow Drill Rate F/S ❑ ❑ ❑ LITHOLOGY 7. SCREEN From (ft).aTo (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment "5 _ 469/7)' 0: ❑❑❑ Mlj Y/N Y/N F/S ❑❑❑ . ' Q 0Mov Y/ N Y/ N F/ S ___ g ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL. 1 ice. Y / N Y / N F / S;.: From (ft) To (ft) Material Description Purpose Y/N Y/N F/S'0 �® Y/ N Y/ N F/ S Y/N Y/N F/S'-- MC Y/N Y/N Fl`S I 1 ❑❑- ❑❑ WELL LOG BEDROCK Water Bearing Zone Drop in Drill Stem Extra Large Chips Extra Fast or STOW Drill Bate Visible aining Staining Loss or Addition Fractures f Fluid of N of ft per foot 9. SITE SKETCH LITHOLOGY UA/1[/A�/ From (ft) To (ft) Code Comment YlNY/N`F/S Y/N Y/N Y/NY,/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y/NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N w_ Y`/NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y/NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N 10. WELL TEST 'DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATERLEVEL (ALL'; WELLS) Yield Time Pumped Date Method (GPM) (hrs & min) Pumping Level Time to Recover Recovery (Ft. BGS) (hrs & min) (R. BGS) Date Measured Depth Below Ground Surface (ft) 12. PERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION Pump Description ❑ ❑ ❑ ❑ Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Developed Y / Fracture Enhancement Disinfected Y / N Surface Seal Type Total Well Depth „jam Depth to Bedrock 14. COMMENTS 16. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abando ed under my supe vision, according to applicable rules and regulations, and this Report is com�late and correct to the best of my knowledge. Driller .' rs` a F Supervising Driller Signature: .. ) �. -" Registration If: Firm: = L Date Com fete a~` Rig Permit #_ NOTE: Well Completion Reports inust he filed by the registered well driller within 30 days of well completion. BOARD OF HEAL74 COPY 1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGIT E Address at Well Locati n: � e4l Propertp Owner/ Subdivision, Name: / i� �� Mailing Add �G{ City/Town: ,£� ° " "f J Ciiy/Town. Assessors Map Assessors Lot #: NOTE:. Assessors Map and Lot # mandatory if Board of Health permit obtained: Yes ❑ Not Required PermiVNumber New Well LJ Abandon Deepen a ❑ Recondition Replace ❑ Other /ELL LOG_ _ Water I Bearing m (ft) To (ft) Zones ❑ _Irrigation JEJ Cable tg El ❑ Air He I ❑ Other ❑ Mud d Consolidated 16. SITE SKETCH Other ROCandype Material neccrintinn Direct Push available 7.WELL CONSTRUCTION, 18. CASING. Total Depth Drilled 40 U From (ft) To (ft) Casing T pe and Material Size I.D. (in) ell Seal Type Date Com�lete / 0,--•- -- - >J'f`��/ 9.SCREEN From (ft) To (ft) Slot Size Screen Tvoe and Material Screen Diameter 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11.'ADDITIONAL WELL INFORMATION Developed? ❑ Yes 7R7 From (ft) To (ft) Material Description Purpose Fracture C 504 t Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ 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) (hrs & min) (Ft. BGS) (his & min) (Ft. FIGS) Date M asured Ground Surface (FT) 14. PERMANENT PUMP (IF -AVAILABLE) 115. NAMEIADDRESS OF PUMP INSTALLATION COMPANY, Pump Description Horsepower Pump Intake Depth (ft), /) Nominal Pump Capacity (gpm) 16. COMMENTS I 11 j I= 17. WELL DRILLER'S STATEMENT .. This well was drilled, altered and/gr, abanj� lied onder;fny su drvision, according to applicable rules and regulations, and I is report is c� fnplete�and%corregt o the best of my knowledge. ) Driller: upervising Driller Signatufe� AA� f f r(vJJJI I, `0 A /--RPnistration #: � I Firm: 148 Pioneer Drive Date: �/ , Rig Permitit: I _LeQMWAtWj M41�rrts must be filed by the registered well drill within 30 days of well completion. BOARD OF HEALTH COPY' - 'f t Dairartm6it of Environmental Management/Divislon of Water Resources WELLONIPLETION REPORT �� A, WELL LOCATION A15 41 (, t /rr: GEOGRAPHIC DESCRIPTION Address� �! eb��' FYyi �' ,ffrwrJ` N S E W. of b�.r,� (Ieeq (cicle) City/Town— Add, Li ear�4 ,arwltt N S E W of rnnk�©Nl�%� Cf�TdI ml.lneenthsl (circle) board of Health permit obtained: yes ❑ no ❑ lnrersect. w/ , �troed) WELL USE. WELL DATA '/y Domestic:❑ Public E],Industrial E]Total well depth /.? it Monitoring Other Depth tobedrock it Water hearing rocklunconsolidaled materlali .Method drilled �%�'-� .Date drilled `/O'fL3 Description - CASING ' : - Water-bearitng zones: : r i v� 11 From To`�y Type 2) From To Length 2 ft. Dlall; D.) In: 31 From To ` .`r't Y `4 { �. Length Into bedrock ft, , . T"i'+ ' Gravel pack well: of, Protective well seal: ,Grout.❑ Other 71 Slot✓ //� len�h ftom 0 to-X STATIC WATER LEVEL (al(wells) Sfaticwater: level belowland surface WELLTEST (production wells) r Drawdown_ft. after pumping mlp. at gpm How measured Recovery_ ` fL' after_hr n. LOG of FORMATIONS COMMENTS .�l��i' Ezj w 14