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HomeMy WebLinkAboutHall St. #87 - 3/14/2002MANSFIELD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Name O ✓1 / f m /9 S Address: - #�qL- S7' Location: a y8 Registered 4m erica j �r 1i( U5 P(- v-cHr Well Driller: P-'o• 6o)c 3s3 L&� Address: %)g /+ 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.) Agricultural (for irrigation of land -in -the business -of agriculture) Fee: Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural Date: Marcy- 1 d&c Z Applicant signature: PERMIT TODRILLWELL The above applicatio It en appr a and permission is granted to drill a well for the following use at _ Domestic Potable (for household use) Domestic Auxiliary (for watering, pools, etc.) _ Industrial/Commercial Potable (for human consumption, including food processing) _ Industrial/Commercial Auxiliary (for manufacturing, etc.) _ Agricultural (for irrigation of land in the rness ) agriculture) Date: (�r ("�y Approved by: the Board of Health NOTE. Electrical permit required, underground cable trench must be inspected Upon Installation of well, call Department of Public Works office at 261-7331 to be added to well list Massachusetts Department of Environmental Management Office of Water Resources 108613 TYPE OR PRINT ONLY Well Completion Report 1�WELL,LCCAIION ;,; (,1?$<(tRTIONAL `'==''LATITUDE ONOITUDE' Address at Well Location: k7 Ala L/-f� r� Properly Owner: / Itsll(t Subdivision Name: Mailing Address: % � %� ✓� %�� Cityfiown: &R ,Cityliowm' Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot If mandatory If no street address available Board of Health permit obtained:, Yes Not Required ❑ Permit Number Date Issued d 2,.11JCORK�"ER�ORJ��p ��rE3 S` ��10 New Well ❑ Abandon ❑ Deepen ❑ Recondition ❑'Re lace ❑Other Domestic In Irrigation Monitoring El- Municipal Industrial ❑Other ❑ Cable ❑'Auger P Air Hammer ElDirect Push ❑ MudRota' ''❑ Other I`:' 5 uvEILO ,'. - ¢ � Permeability High Low a Unconsolidated a n o Other Consolidated Rock Type90 �1C]OH" tra6){aermAneatiardmarliowlth;diaiancda).,- Q1 i From (it) To (ft) JD f t% 7 t 1c�(J "D5- 7. WELL.CONSTRt10TIQN'=,"' U: CASING" -- Total Depth Drilled J'f5" From (it) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type Date Drilling Complete x .5r_e_ s 9,SCREEN ' From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10, FITER.PACK/ GROOIABANDDNMENT MATERIAL 177777711. ADDITIONAL WELL INFORMATION From (it) To (ft) Material Description Purpose Developed? 1�1- Yes El NoFracture Enhancement? ❑ Yes 7- No Method Disinfected? Eyes ❑ No 1Xi WEI:LTEST DATA,(PF;()DUGT[QN WEI13)'' �C WATER LEVEL (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) !/ 7Y5 r 30 114,'PERMANONT PUNpP;"(iF'AI/AILABt E) 15. NAMEIADD))ESS OF PUMNNSTALLATION COMPANY Pump Description /J C76 /© Horsepower � Pump Intake Depth 0> (ft) Nominal Pump Capacity /_7 (gpm) _,ins -CaA �r`d�Fr� y i f S f " j>G, c r 3 16;�'COMMENTS;," )7. WELL L)Rl) Ei#`,S S AT MEN _ , "-, '- This well was drilled and/ at)a doned under my supervision, according to applicable rules and regulations, and this repo is complete and correct to the best of my knowledge. 1/ � at2 �T /% A - z_ - „_� Z Registration #. U � ;%� Driller: Supervising Driller Signature g Firm: ' �&IAe✓l ' � — G _ _ _ Date: r i Rig Permit #: NOTE. Well Completioa Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTHCOPY