HomeMy WebLinkAboutGilbert St. #140 - 6/30/2005Massachusetts Department of Environmental Management
Office of Water Resources . , Fa 11
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE LONGITUDE—'° A
Address at Well Location: ` " Property Owner/Client f ell 131��
Subdivision Name Mailing Address p a (, 4
City/Town: 1)"w; , v .� > Cityfrown:
Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot #mandatory if n , t eet address able
_
Board of Health permit obtained: Yes [ Not Required Cf Permit Number s-ok - Date Iss
2. W 9RK PERFORMED
3. PROPOSED: USE
14. DRILLING METHOD
E` New Well ❑ Abandon
❑ Domestic Irrigation
O Cable ❑ 'Auger
El Deepen El Recondition
❑ Monitoring El Municipal
❑' Air Hammer O Direct Push
❑ Replace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rota' ❑ Other
5. WELL LOG
Water
Bearing
Unconsolidated
Consolidated
16. SITE
SKETCH,(use Permanent landmarks with distances)
=
m
a
Other
Rock Type
From (ft) TO Nft
Zones
o
m
N
m
Mater al
Descrption
��t7�tts
a�Yri o-� e"wA
7. WELL CONSTRUCTION
8.sCASING
Total Depth Drilled
From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type
M Date Complete C�y 5°17 t6a °"r.�-,� �3° x ` oV JAY y H
r.
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL
11. ADDITIONAL WELL INFORMATION
Developed? Ln` Yes ❑ No
From (ft) To (ft) Material Description Purpose
Fracture -
Enhancement? ❑ Yes ❑`No
Method e
Disinfected? El -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 Measured
Ground Surface (FT)
.v ,, �F?v ..���•.-.
E
.ter °d
e°�./r=s Fz,
,°C`3 t
6:,-,�.,a,,
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
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: Supervising Driller SignatuRegistration # ',�
5
ra'.6 PiiB �yff Nr 7 h ^:4,
Firm:/ Date Rig Permit#�
NOTE: Well Completion Reports most be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY