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Home My WebLink AboutJames St. #45 - 4/18/2003w �l � w�e ✓ APPLICATION FOR PERMIT TO DRILL WELL Name Address: q � ---� S Z � , Location: Registered " Well Driller: f, lJ S V Address: TYPE OF WELL: UY ks H o t -� t0 q - 5-s&�9 omestic 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: /Dom estic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural Date: y I 1 KD.3 Applicant Signaturc�� .� r ► 1 I; ,FT. The above application has been approved and permission is granted to drill a well for the following use at _�S_j� Domestic Potable (for household use) �_ omestic 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: i 03 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 lisp • Massachusetts Department of Environmental Management Office of Water Resources 111703 TYPE OR PRINT ONLY Well Completion Report 1.WELL.400pTION GPS (OPTIONAL) LATITUDE,a NITUDE Address at Well Location: Property Owner: �76f2G'W-,9) llle i✓I�/ 'G- 9 Subdivision Name: Mailing Address: City/Town: City/Town:`c Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes [A-'- Not Required ❑ Permit Number Date Issued 3;,PFI001SED USE , , . „" ❑ Domestic ❑ Irrigation ❑ Monitoring ❑ Municipal ❑ Industrial ❑ Other 11LINO'IAETHOi7,'m ❑ Cable ❑ 'Auger y ❑ Air Hammer ❑ Direct Push ❑ Mud Rotary ❑ Other ❑ New Well ❑ Abandon ❑ Deepen ❑ Recondition ❑ Replace ❑ Other ,iIIELLIpG„ ' or. W Q Pennea6ility HignL ow ° Unconsolidated n m y m m Other Consolidated Rock Type m,SiTCH(u®eyermAngt`ter°dmarks>ytlhdlafnpa�' '. ' / ! /? r' rr /1�<le an �aU53 Ak�l From (it) To (ft) WEI L+ ONSTFtUCTION ` 8. CASING —77777777777777 7-77 7, Total Depth Drilled From (ft) To (it) Casing Type and Material Size O.D. (in) Well Seal Type Date Drilling Complete I r, 9.=SCFiE: hl ;; J From (it) To (it) Slot Size Screen Type and Material Screen Diameter y 10. PILTER�P CCK,/ GROUT! ABANDONMENT MATERIAL 91. ADDITIONAL WELL NFQRMATIQN From (ft) To (it) Material Description Purpose Developed? ®Yes ❑ No Fracture Enhancement? ❑ Yes ❑-IN-0 Method "' Disinfected? ©`des El No i r lEL TEST DA fA (PRpDU TiON WELLS) „' 3 STATIC WATER' LEUPL (ALL WELLS)--, Yield Time Pumped Drawdown to Time Recovery to Date Method (GPM)'"'. (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Depth Below Ground Surface (FT) / c-id- ZU _/ Cd; PEF#MAtENT,.PUAI)P (IF. AYAILABLIE) �� 7 �. NANIEIADDRESS-0F PUMP INSTALLATION COh1PANY Pump Description r �c POWIZdd Horsepower Pump Intake Depth `t'(ft) Nominal Pump Capacity ifs (gpm) 6 7�jC i-✓ (r. ¢ C�•di®nk O�1 �6x�OM�YJENT;S; �eN�'i�CiaiP..!_�.,�•,�r�R;ar-� i7 11fthATiiLi Ef1'?%N,T,„' This well was drilled and/or abandoned under my supervision, according to applicable rules 7 � and regulations, and this rep9rticompI�te and correct to the best of my knowledge. Driller: S % Supervising Driller Signature: - -'-Registration #J I A LE Firm: .6z' �' ✓ G �7�� lY'.S ' -' Date: RigPermit #: ( I l �P ?S �� I NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH`COPY. .