HomeMy WebLinkAboutJulia Ln. #5 - 2/28/2019e�6
Commonwealth ofMassachusetts Town of MapsV&d 28 Pm2.27
Town of J Mans field 8 Park Row
Mansfield, MA 02048
Board of Health
Application for Permit to Drill Well
NAME OF OWN R: 4IA2-3'/' �
Oct CG-
ADDRESS OF OWNER: !` 5 �Cy� �% j� L/w
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TOWN / STATE / ZIP: U
TELEPHONE No:
REGISTERED
WELL DRILLER: P,,4 (4 L_
MA LIC #: ,
BUSINESS Pe)(]27x �' l�
ADDRESS:_5Z-0�/-t -;As'v/ 'Gc:- r-
p�9 7,6
TYPE OF WELL: 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.)
XAgricultural (for irrigation of land in the business of agriculture)
FEE: O Domestic$75.00 O Industrial/Commercial$75.00 O Agricultural$75.00
DATE: APPLICANT SIGNATURE
Permit to Drill Well
The above application has been approved and permission is granted to drill a well for the following use
Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
H Industrial/Commercial Auxiliary (for manufacturing, etc.)
H Agricultural (for irrigation of land in the business of agriculture)
DATE: ,i i `) �tJ\ APPROVED B�
Fo the Board of Health
NOTE. Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Department of Public Works at
508-261-7330 to schedule an inspection.
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection
Well Completion Reports
Well Driller
Please specify work performed:
New Well
Please specify well type:
Irrigation
Number Of Wells:
Well Location
In public right-of-way:
rYes (` No_
i
Subdivision/Property/Description:
Property Owner:
MANSFIELD WILLOWDALE ESTATES LLC
Engineering Firm:
Address at well location:
Street Number:
Street Name:
5 --
JULIA LN
Building Lot#:
Assessor's Map #:
16
28
Assessor's Lot#:
ZIP Code:
02048
Cltyrrown:
MANSFIELD
GPS
North: West:
42.01662 71.22241
Mailing Address:
I✓ click here if same as well location address,
Street Number: Street Name:
5 JULIA LN
City/town: State:
MANSFIELD MASSACHUSETTS
ZIP Code:
02048
Board of health permit obtained:
r Yes (" Not Required
Permit Number: Date Issued:
02282019 02/28l2019
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Well Driller Program
011 Well Completion Reports(General)
Well Driller - General Well Form
DRILLING METHOD
Overburden
Bedrock
Puger _
Z-Choose Bedrock--
WELL LOG OVERBURDEN LITHOLOGY
From(tt) To(ft)
(
(Code Color
Urban Fill -- Jf Brown
Sand And Gravel _III Brown
WELL LOG BEDROCK LI7HOLOGY
(From (it) To(k) Code Comment
Drop in drill
Extra fast or slow
Loss or addition
Comment
stem
drill rate
of fluid
r
Fast r slow
r —
_.-
YES NO
_ _ _:
Loss Addition
r
r Fast G Slow '- (
r r
)I YES NO _- i
i Loss Addition
Loss or
Extra
)top in
Extra fast or
Visible Rust I
addition of
Large
frill stem
slow drill rate
fluid
Staining
1 Chips
r r
r r
r r
l� Yesi
lr
YES t.O
Fast Slow
Loss Addition
-e
ADDITIONAL WELL INFORMATION
r Yes rNo
Developed ( -_I Disinfected G'Yes r No,
Total Well Depth 25 Depth to Bedrock
Surface Seal Type (None - fracture Enhancement f Yes G. No.,
CASING it Is Casing above ground??
[From i7o Type Thickness -
Polyvinyl Chloride - JI (Schedule 40
SCREEN IJ No Scree
From _ To
�22 --. f25 j - Stainless Steel Well Point J�
WATER$EARING ZONES (r DRY WEL%
From To Yleltl (gpm)
_-
PERMANENT PUMP (IF AVAILABLE)
Pump Description 2 Wire Constant Speed
Submersible
Pump Intake Depth (ft) 18
ANNULAR SEAL I FILTER PACK
[From To Material 1
Horsepower
Nominal Pump Capacity (gpm)
Weight IMaterial 2
Slot Size
C 12-
1A
10
Diameter Dnveshoe
(r Yes-"_
Of
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Well Driller Program
A%Il Completion Reports(General)
1
0 r25 Native Material + �l Choose Materal
WELL TEST DATA
Tlme Pumped
Pumping Level (ft Time To Recover
Recovery (ft
Data Method
(gpm) (HH MM)
BGS) (HH:MM)
BGS)
[03128/2019 Constant Rate Pump
�Yieltl
,�� �10 101 00
�2 1 100
WATER LEVEL
Static Depth BGS (ft) I Flowing Rate (gpm)
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this report is complete
and accurate to the best of my knowledge.
STEPHEN Monitoring [M] Supervising Driller EMMONS,
DrillerHAASE Registration # 788 Signature PAUL,
PAULS WATER Date Job Complete
03/28/2019
Firm WORKS, INC. Rig Permit # 220 �
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
FL11VMassachusetts Department of Environmental Protection
eDEP Transaction Copy
Here is the file you requested for your records.
To retain a copy of this file you must save and/or print.
Username: PAULSWATERWORKS
Transaction ID: 1096038
Document: Well Driller
Size of File: 359.16K
Status of Transaction: In Process
Date and Time Created: 4/1/2019:4:36:57 PM
Note: This file only includes forms that were part of your
transaction as of the date and time indicated above. If you need
a more current copy of your transaction, return to eDEP and
select to "Download a Copy" from the Current Submittals page.