HomeMy WebLinkAboutBonney Ln. 14 - 5/10/20000f1
MAY ( 0
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Registered
Well Drilh
TYPE OF WELL:
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
V
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:
Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permission is gr ted to drill a well for the
followinguseat_NIC14Si16 C
_D estic Potable (for household use)
omestice 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)
�Ar
Date: 0 ` 0 Approved by: 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
261-7331 to be added to well list
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+"` w Department of Environmental Management/Division of Water Resources
a WELL COMPLETION REPORT
V` GEOGRAPHIC DES
Address N
WELL LOCATION S E W of
Address � 11t t lreeq (circle)
y c c r� orttit r r 1 E
city/Town -�---- (road)
Well owner `'S CE) �O N W of
(circle)
Address--- lml. m reams)
�Y, _ -naC�. intersect.
es
:WELL USE
Domestic Public ❑ Industrial
Monitoring ❑. 0therzw�
WELL DATA - ---
Total well depth a__ 44—n it,
Depth to bedrock _.- $fin ft.----- -
Water -bearing rock/uacoasolidated-material"
Method drilled �iR�- Description - `'-
Date drilled 7 {� -��� Water -bearing zones:
C 1)From_.- {c-� --To�-
CASING To------
STi=1=, t .0 l_i#�_ 2) From_ ------
Type _ 3 ---- 3) From_----To-----
Length.�.Q-ft• pia(LD.) ' in.
{ O fP. Gravel pack well: dia.-------
Length into bedrock _---- Hin
Protective well seal:E Screen: from_ -to_
rWELL
❑ Other i, =
Slot# length ---
WATER LEVEL (all wells)`�ater level below land surface r -tt. DatedEST (production wells) �gpmw ft. after pumpinghr.min. at���,I, ft, after hr. '-'min.
easured�tt.x.�-+>r'-Recovery
LOG of FORMATIONS
Materials From
Q
Driller \ �_
Address „ T.
Supervising Driller
BOARD OF HEALTH COPY