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HomeMy WebLinkAboutForbes Blvd. #89 - 2/10/200301/3o/2003 THU 11:25 FAX 508 261 7425 TOWN OF MANSFIELD Z 002/003 MANSFIEILD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Name Cabot Corporate Center Limited Partnership Address; 89 Forbes Boulevard Location: Mansfield, Massachusetts Registered Well Driller; Northeast Water Wells Inc. License # 207 Address: 2 Tolles Street, Hudson, NH 03051 TYPE OF 'WELL: Domestic Potable (for household use) >(_ Domestic Auxiliary (for watering, pools, etc.) Industrial/Commercial Potable (for human consumption, including food processing) A Industrial/Commercial Auxiliary ff=:m u£actadug,_etc,.) irrigation system _ Agricultural (for irrigation of land in the business of agriculture) Fee: x Domestic $10.00 -54 Industrial/Commercial S100.00 Date: Applicant Signature: N/C Agricultural PERMIT TO DRILL WELL The above application has been approved and permission is granted to drill a well for the following use at jj _ 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) Dater Approved by: pDr the Boat& tkkOMELD Payment : sre.eo Receippt N : 184344 .NOTE.• Electrical permit required; underground cable trench ngq, ta¢ranitp&0tdj*: CRBOT CORP Upon Installation of well, call Department ofPuKtj4yWorks OA gfP CENT LTD 26I-7330 to be added to well list Massachusetts Department of Environmental Management Office of Water Resources 112550 TYPE OR PRINT ONLY Well Completion Report 1, WELL LOCATJON , AL) ww Address at Well Location: Property Owner:«��> Subdivision Name: Mailing Address CityfTowm M0,15 1,d 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 Z WORK PEBFORNIED' _ '' 3: RFtOFOSED USE URILLING.METRQA ❑ New Well ❑ Abandon ❑ Deepen ❑ Recondition 6Z Replace ❑ Other ❑ Domestic E,11irrigation ❑ Monitoring ❑ Municipal ❑ Industrial ❑ Other ❑ Cable ❑ Auger ®'Air Hammer ❑ Direct Push ❑ Mud Rotary ❑ Other 5. WELL LOCa ; m 3: Permea45 High 6ilily Low a O m Unconsolidated v W ce g m Other Consolidated Rock Type $I ;SICEtC}j=(Use petmaoyrinmarksvniva(�rsn�es).; 4 oqq/- �I I AA ©< New w�Il From (ft) To (ft) 0 Aw�p OAS V L> ,<, 7. WELL CONSTRUCTION 8, CASING Total Depth Drilled , U_r, Date Drilling Complete / 3 o j From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type U . o 9.SCREEN From (ft) To (it) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK 1 GROUT[ ABANDONMENT MATERIAL " `y1. ADDITIONAL WELL INFORMATION From (ft) To (ft) Material Description Purpose Developed? ❑ Yes M-140 Fracture Enhancement? ❑ Yes [11� No Method Disinfected? 2 Yes ❑ No - 12. WELL TEST DATA, (PRODUCTION WELLS) t. STATIC WATER �LE4EL (ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Date Method (GPM) ''`::(hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Depth Below Date Measured Ground Surface (FT) 14. PERMANENT PUMP (IF AVAILABLE) 4$j'NA0F4ADORE$$ OF POMP INS7ALLA`"I—OR COMPANY, S Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS, 17. WELL DRILLER'S"STAT-ea NT ` This well was drilled and/or abandoned under my supervision, according to applicable rules and regulations, and this report is c (nplete and correct to the best of my knowledge. Driller: e iDJ if /(�y F 3 Su/pervising Driller Signature: Sdr . 'Y' 4 Registration #: /16112 Firm:1yorA11ef571 VVIq-IF�f ti//(5 /Date. � /�y' U� Ri Permit#: � ����� NOTE. Well Completion Reports mast be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH.COPY. Massachusetts Department of Environmental Management Office of Water Resources TYPE OR PRINT -ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) ':LATITUDE" LONGITUDE ' Address at Well Location: , Property Owner. Subdivision Name: Mailing Address City/Town: Al er n 5 F F 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 ❑ Permit Number Date Issued 2. WORK PERFORMED 3. PROPOSED: USE 4. DRILLING' METHOD ❑ New Well ❑ Abandon ❑ Domestic Irrigation ❑ Cable ❑ Auger ElRecondition ❑ Monitoring ❑ Municipal ET -Air Hammer ❑ Direct Push Vaspen e lace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rotar ❑ Other 5. WELL LOG Cr Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances) W H Permeability o m m From (ft) To (ft) Q High Low m m a m Other Rock Type 0 / 7. 00 U l-� Yf5nr�i k tyen, W. 11 7. WELL CONSTRUCTION S. CASING Total Depth Drilled 2 U t� From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type Date Drilling Complete o 2 t> S pn / -� tP i✓p Lire-c Sdto<, o // 0 3 O 80.>, )chi yo 9.SCREEN From (ft) To (It) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT 7 ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? ❑ Yes ®No From (it) To (ft) Material Description Purpose Fracture Enhancement? ❑ Yes E 'No Method Disinfected? M Yes ❑ No 12. WELL TEST DATA (PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM) (his & min) (Ft. BGS) (his & min) (Ft. BGS) Date Measured Ground Surface (FT) g ,) Air l,`fl z z _ �0 05 2 t 001 z ' 14. PERMANENT PUMP (IF AVAILABLE) 15, NAME/ADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower wQ irr wr l } Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 2 (Ij/lr's S._ 16. COMMENTS', 17. WELL DRILLER'S STATEMENT This well was drilled 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: TW&OA ��'i�P"5 Supervising Driller Signature: ��'- ? �//���° �" � Registration #:1 1 "71 61 21 A101111et?d I/Vdlrr wr//5 LI ri-> 12121, Firm: Date: Ri Permit#: NOTE. Well Completion Reports most be filed by the registered rveR driller within 30 days of well completion. BOARD OF HEALTH COPY Massachusetts Department of Conservation and Recreation Office of Water Resources 11, 5 0 1 TYPE OR PRINT ONLY' Well Completion Report 1.WELL LOCATION `I GPS (Required) North 7 ..,West Address at Well Location: } �/ �,m F(� /5'1✓d Property Owner/Client x Subdivision Name Mailing Address: � City[Town: `0 ac 0 L � �� �/- 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 to, Permit Number Date Issued 2. WORK PERFORMED 13. WELL TYPE �fY"❑ 14. DRILLING METHOD Overburden I Bedrock 6. CASING From (it) To (ft) Type Thickness Diameter ❑ ❑ ❑ ❑ ❑❑❑ ❑ ❑ ❑ 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 SCREEN From (ft) To (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment Y/N Y/N F/S ❑❑❑ — — — Y / N Y / N F / S ❑ ❑ ❑ Y / N Y / N F / S 6_ ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL Y / N Y / N F / S - From (ft). To (ft) Material Description Purpose Y/N Y/N F/S e(D "s�a (.,' �0° d❑. Y/ N Y/ N F/ S / ED Q t ❑❑. Y/N Y/N ;F/S ❑❑ El El WELL LOG - BEDROCK Water BE Zone Y/N Drop in Drill Stem Y/N Extra Large Chips Extra Fast or Slow Drill Rate FY'S Visible Rust Staining Loss or Addition Fractures of Fluid Hof per foot El El El El 9.'SITE SKETCH LITHOLOGY r , )i ° t 0YlNY/N j i From (ft) To (ft) Code Comment Y/NY/NF/SY/NY/NthAfAG� 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 F/S Y/N Y/N Y/ N Y/ N F/ S Y 1 N Y/ N Y/NY/N F/S Y/NY/N i 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) Yield Time Pumped Pumping Level Time to Recover Recovery Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) 11. STATIC WATER LEVEL (ALL WELLS) Depth Below Date Measured Ground Surface (ft) 12. PERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION Pump Description ❑ El ❑ ❑ Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Developed Y / N Fracture Enhancement Y / N Disinfected Y / N Surface Seal Type ❑ ❑ ❑ Total Well Depth Depth to Bedrock 14. COMMENTS 15."WELL DRILLER'S STATEMENT This well was drilled, altered and/or bandoned under my supervision, according to applicable .:� rules and regulations, and th s r �� is,,tcomplete and correct to the best of my knowledge Driller ° , Ill /' ' -e Supervising Driller Signatur", `7 h Registration #: I I z I I 3 Firm: DateComelete: % .� i��> Riq Permit#: NOTE. Well Completion Reports must be filed by the registered well dilller,(vithin 30 days of well completion. BOARD OF HEALTH COPY