HomeMy WebLinkAboutGriffin's Way #4 - 5/2/2006MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name 3CV_nU e_t I cQA4.LM O.`j
Address: `p 'WCI Telephone
Location: \A l a,v i f)i60 ;-ki P .Ica
c<e_oSa j q-3S� r(�
Registered
Well Driller: Y aY P Itri <�' tg ✓1/1 C C' MA Lic # q
Address: (� S
TYPE OF WELL:
Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)(C"'bt 1'6gcf 1 On
_ 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:'X Domestic $10.00 _ Industrial/Commerei ; 0 N/C Agricultural
Date: - Applicant Signature: ,
J'
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at �/ (-7>,^; CW� S t�-)CL 4,
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)
Date: `J -Z-o (o Approved by: - (pr j e ) 6
For 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
261-7330 to be added to well list.
Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION"
GPS:(OPT)QNAL) LATITUDE= LONGITUDE
Address at Well Location: POW'/ Property Owner: Y'' i °+'
Subdivision Name: Mailing Address:
City Town: /Z l Pat r y / i 0 City Town: f f fI n Y/ [ l/
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes C Not Required ❑ Permit Number Date, Issued
2. WORK PERFORMED
3. PROPOSED USE,
4. DRILLING METHOD i
New Well ❑ Abandon
IED
❑ Domestic D,lrrigation
❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
❑ Air Hammer ❑ Direct Pu h
ElReplace ❑ Other
Industrial ❑ Other
❑ Mud Rota' Other ��,'tM !4 42
5. WELL LOG
m
Unconsolidated
Consolidated
16, SITE
SKETCH (uselpermanentlanamorkgivufi:distances)
W
Permeability
it tl)
From (ft)
To (ft)
High
Low
m
3
m
Other
Rock Type
YP
$a
0
if
SY___
7. WELL CONSTRUCTION
8.
CASING
Total Depth Drilled rI From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
r 5 / 47 1 ti 77 e. i�1 A' I �,fd'1 jf
/ 5J /
Date Drilling Complete
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
QS
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? 9--Yes ❑ No
From (ft) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑, No
12. WELL TEST DATA (PRODUCTIONWELLS)
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)
.a
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMFJADDRQQEaaSS OF PUMP INSTALLATION COMPANY
Pump Description /',AjP Horsepower
Ganellato`e
65 LAUREL ST.
Pump Intake Depth (ft) Nominal Pump Capacity G! (gpm)
16. COMMENTSr
17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this repol is complete and correctto the best of my knowledge.
/ yJ '
Driller: �l °°�dtnnl .>t/fr'kGiPf)4"-r)0 9,tYipervlsing Driller Signature: i"4�'>f �'.) ���`�"f fr M-4— Registration #:10191 � )
^�%-r//r �- fi l '` C�./f �� �, r;, ���.! �,: ;: Date: r0! l 1) n Rig Permit #:
Firm: _i
NOTE. Well Conmpletion Reports must be filed by the registered well driller, within 30 days of well completion.
BOARD OF HEALTH COPY