HomeMy WebLinkAboutFarm Pond Path #11 - 4/1/200403/30/2004 TUE 14:11 FAX 508 261 7425 TOWN OF MANSFIELD 0 0 2 / 0 0 2
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MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name r%'49" / A�el G�
Address: Telephone 3 O 3 - 3 3 CV-)
Location:��o�"e lhaxE-) ..
Registered
Well Driller: MA Lic #
Address:_ (. fI/LC.LE Ole- )✓f 7"IV- 1`1el-,i>
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,)
AItural (for irrigation of land in the business of agriculture)
Fee: _ Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: AjLULC4? 96, 6Y Applicant Signatur
PERMIT TO DRILL WELL
The above application has been approved and permissio granted to drill a well for the
following use at 1l O!z �Cs � 10) -'s t
2/ 02 C, 6
__ 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 busi �Forthe�BoardofH�ealth
oof agriculture)
7
Date: "i-D Approved 5—
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
Massachusetts Department of Environmental Management 12 Qd
Office of Water Resources
'TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE LONGITUDE
Address at Well Location: & '�471. Property Owner: le j
Subdivision Name: Mailing Address: /Z ays� s'�',��i %iP h y rf
Cityrrown: 1dl4A S/r ' .;:..City/Town: .,+r7�rt' S' �r .+%� r" :2'5e rti'...
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot #mandatory if no street address available
Board of Health permit obtained: Yes CC4 'f Not Required ❑ Permit Number Date Issued
Z WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD r
Clew Well ❑ Abandon ❑Domestic E3kfrrigation ❑ Cable uger
❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota ❑ Other
5. WELL LOG
rr
Unconsolidated
Consolidated 6. SITE SKETCH (use permanent landmarks with distances)
From (ft)
To (ft)
W
~Q
Permeability
High
Low
—
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m
Other
Rock Type �i pt'f a�✓,�c�
9 Lrr.
✓✓3.St1.
dev
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7. WELL CONSTRUCTION -
8. CASING
Total Depth Drilled c
From (ft) To (ft) Casing Type and Material Size O.D.(in) Well Seal Type
Date Drilling Comple
,2 1 e--,
L
S. 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 (it) Material Description Purpose
Developed? ®-- 'es ❑ No
Fracture
Enhancement? ❑ Yes ❑ No
MethodC96zt��/-e`✓
Disinfected? ®..des"' ❑ 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) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
date Measured Ground Surface (FT)
4
Z AIC
AA I ✓d m,ti--
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7/hL
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14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEtADDRESS��OF,, PUMP INSTALLATION COMPANY �.
Pump Description j %✓� % Oi ,O�It,(A Horsepower �
Intake Depth ft Nominal Pump Capacity (gpm)
��✓r '� Crr �r l ,
r f rL
7' rPumP
16. COMMENTS
17. WELL DRILLE:R'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is and correct to the best of my knowledge
7 h i
Driller: Supervising Driller Signature; Registration #:I
r
r
Firm: -- .,/`% ./� ..;'r../�„�� �... Date `F'F6 .''i�a' Rig Permit#: ( Le`�
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY