HomeMy WebLinkAboutForbes Blvd. #305 - 5/19/2006C� Massachusetts Department of Environmental Management
QU Office of Water Resources B 145348
wwwwo vvn.pitevoul, neport
1. L I N
GPS ( PTIONAL) LATITUDE —° LONGITUDE—' ," DATUM
Ad - at Well Locati n! cy1 Property Owner/Client: r e -
Sub vision �,/ F r �.i /7" Mailing Address: y 9 e J' CL -
City/T 0y / % Sv /7 City/Town: L Hai s'
Assessors Map Assessors Lot #: NOTE: Assessors Map. and Lot # mandatory if no street address available
Board of Health permit obtained: Yes ❑ Not Required ® Permit Number Date Issued
2. W RK PERFORMED -
3. PROPOSED E -
4. DRILLING METHOD
New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑- Replace ❑ Other
❑ }¢omestic '❑ Irrigation
Monitoring ❑ Municipal
❑ Industrial ❑ Other
❑ Cable Auger
❑ Air Hammer ❑ Direct Push
❑ Mud Rotary ❑ Other
5. WELL LOG
iWater
Bearing
Zones
Unconsolidated
Consolidated
6. SITE SKETCH. (Use permanentianamarks with distances)
From (ft) To (ft)
b
m
o°
g
a m
Other
Material
Rock Type
Description
30 /bfOd
� f0
Q
�
7. WELL CONSTRUCTION
6. CASING
Total Depth Drilled 121
Date Complete /
From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type
Q'
, -
Ste. 0.,0l-C
n'
9. SCREEN -
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
13
. U( O,
c-
"Z •"
10. FILTER PACK / GROUT,/ -ABANDONMENT MATERIAL
11. ADDITIONAL WELL INFORMATION
From (ft) To (ft) Material Description Purpose
Developed? ❑ Yes 14'IS
Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑ No
t
t
' 'CQ. skm-/
12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdewn to Time to Recover Recovery to
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (FL BGS)
Date Measured
Depth Below
Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
/ O
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.
Driller: ' ult7T yt Supervising Driller Signature }1 =''f Registration #:
r
-Tee 1 J2VRi Pemit#: ) II ii
IFirm: C (t
NOTE: Well Completion Reports mast be filed by the registered well •driller within 30 days of well completion.