HomeMy WebLinkAboutJustin Dr. #2 - 6/14/2007MANSFIELD
OF HEAL
Name
Address:
Location: .2
Telephone 337•- %JP 3D
Registered
Well Driller: P y MA Lic #
TYPE OF WELL:
_ Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
T 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: L-�Domestic $10.00 _Indt
Date: a b ` Applicant
Agricultural
PERMIT TO DRILL WELL
The above application has been approved 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 business of agriculture)
Date: 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
261-7330 to be added to well list
Massachusetts Department of Conservation and Recreation
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (Required) North West-- 0
Address at Well Location: j Property Owner/Client: & Z" -�/")
Subdivision Name: Mailing Address,
_7"
City/Town: City/Town: -_4
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory it no street address available
Board of Health permit obtained: Yes [71-` Not Required E:l Permit Number — Date Issued
2. WORK PERFORMED
3. WELL TYPE
4. DRILLING METHOD
6. CASING
—Overburden
Bedrock
From (ft) To (it) Type Thickness Diameter
El 1:10
1
1
5. WELL LOG
OVERBURDEN
3,,:,tien`g
Bearing
Zone
Lossor
Adult
of Fluid
Drop in
Drill
Stem
Extra
Fast o r
Slow
Drill Hate
1:1 El El
LITHOLOGY
7. SCREEN
From (it) To
Color Comment
1
B, R
Y
Y
F
From (it) To (it) Type Slot Size Diameter
El [A El
ff
4,f� a
Y /11M
Y N—
S
El El El
gya
J(ft)Code
0
N
`VQ N
S
El El El
I
Y N
Y
8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL.
Y N
Y N
F S
From (ft) To (it) Material Description Purpose
Y N
Y N
F S
'o�
El Ell
El El
Y N
Y N
I S s
El El
El El
Y N
Y N
F /_S_
:1
Y
N Y
N
F / S
El El El El
WELL LOG
BEDROCK
Water
Bearing
Zone
Drop in
Drill
Stem
Extra
Chips.
rir'
Fast.r
slow
Drill Rate
Visible
Rust
Staining
Loss or
Addition Fractures
of Fluid
# of
per fool
9. SITE SKETCH
LITHOLOGY
r cp a
N)
From (it) To (ft)
Code
Comment
Y / N
Y / N
F S
Y N
Y N
Y N
Y I N
F S
Y N
Y N
Y N
Y N
F S
Y N
Y N
Y N
Y N
F S
Y N
Y N
Y l N
Y N
F SJY
N
Y N
Y I N
Y N
F S
Y N
Y N
Y N
Y N
F S
Y N
Y N
w.
n i""',
Y N
Y N
F S
Y N
Y N
Y N
Y N
F S
Y N
Y I N
N
Y / N
10. WELL TEST DATA
(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
11. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Pumping Level Time to Recover Recovery
Depth Below
Date Method (GPM) (his & min) (Ft. BGS) (his & min) (Ft. BGS)
Date Measured
Ground Surface (ft)
12. PERMANENT PUMP (IF AVAILABLE)
13. ADDITIONAL.WELL
INFORMATION
Pump Description arD EYEI Horsepower
Developed,7
yj, N Fracture Enhancement Y N
Pump Intake Depth (it) Nominal Pump Capacity —1-P (gPM)
Disinfected(`Y) N Surface Seal Type [J"E I E I
Total Well Depth Depth to Bedrock
14. COMMENTS
I
15. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision, according to applicable
rules and regulations, and this,reporbis cqrnjp�te,ancl correct to the best of my knowledge.
Driller: -v Supervising Driller Signature:,/" — . ... . —Registration #:(
X
Firm: Date Complete: _L.,, Rig Permit If: L—L—L I I
N07E.- Well Completion Reports most be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY