HomeMy WebLinkAboutBrook St. #79 - 9/22/1997• I 11 1 1 1 :I '
APPLICATION FOR PERMIT TO DRILY WELL
Name
Installer
TYPE OF WELL:
soy Wr'lf Dn(fr�'1
Domestic Potable (for household use)
omestic Auxiliary (for watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
:::Agricultural
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: _ ) Applicant
PERMIT TO DRILL A WELL
The above application has b approved and permission is granted to drill a well for the
following use at %G 2Y-4;��
_Domestic Potable (for household use) C>G omesric Auxiliary (for watL,..ag, pools, e—tc. )
_lndustriaUComn.erc;al'� ctable (for human consumption, inciudi .o t ;. ao� sing)
—industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: `L7 Approved by:
For Board of Health
NOTE: Electrical permit required; underground cable trench must be inspected
l
Department of Environmental Management/Division of Water Resources
WELL COMPLETION REPORT
'
WELL LOCATION GEOGRAPHIC DESCRIPTION
Addresses ,?{btg N S E W of
reed , 4
Cit JTOwn Yl9.�l,s c /�. 'r/ �% /2 w
y _'_may_-,--r'c- r. A
Well owner—� �✓v B !roan! �.$,
Ad: -dress ¢%>/E - - ////i N S
In tenihslln tenlnsl dre al `^
❑ intersect. w/ 4%
Board of Health permit obtained yes, �i noru.d
WELL USE r WELL DATA �+
Domestic d'Publid❑ Industrial, ❑ Total well -depth ft.4�p/%-
Monitoring ❑. Othe- Depth to bedrock �!t r ft.• _ `
Waterbearing fockhmconsolidated materlaO
Method drlllecl.a g z4'4
De'cription �G �G
Data drilled Wa( er-bearing zones:
CASING -lftl From.. R' To
/ r Ff
Type � r � � 1.21 From ;2A ZTo
Length Z.4_ft. DIa(I.D.(6' in. - 31 From To
Length into bedrock "-7L'�it•. Gravel pack well; dia.
Protective well seal: '
Screen: dia. ,
Grout; l� other(, Sloth length _from_to'__;
STATIb WATER LEVEL (all,wells) (
Static water,level belowaand surface fL Date
` WELL TEST(productionwws)
I� Drawdown —ft.- aftor pumping T ._. hr._min, at_,65;!� gpm
How measurad'AZ ecuvery �?_.O ft. after_hr.— 2p min.
i o
LOG of FORMATIONS-!- COMMENTS, - a
Materiels - From / T-
i
Driller V..,I,T �a t
,.N 5•;'. Firm.°-62.61v// a,.,
i /
` I Address ` -r -
',.:. / �T
i
City/Town f+
I Supervising Driller Reg!<.
T
{ S/ n lore b trnsTn rc see'red"we/r ax,
I
I """"rr'"�'ly BOARD'OF HEALTH COPY