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HomeMy WebLinkAboutLongwood Cir. #29 - 9/2/1997Name APPLICATION FOR PERMIT TO DRILL WELL l.AJrn a r r )orcia� v jn la s a �dd& Crr e� Location S Installer Address, TYPE OF WELL: 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: _Domestic $ 10.00 Industrial/Commercial $ 100.00 V/C/Aggricultural Date: �_ Applicant Signature: &mil PERMIT TO DRILL A WELL The above application following use at and permission is granted to drill a well for the D mestic Potable (for household usel` mestic Auxiliary �,jr watering, pools, et_c. j _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: 1 �� Approved by: �C For the Board of health NOTE. Electrical permit required; underground cable trench must be inspected Massachusetts Department of Environmental Management Office of Water Resources 1 689 TYPE OR PRINT ONLY Well Completion Report 1. WELL LQCAtl0fi GPS (OPTIONAL) LATITUDE 7777WFuDE Address at Well Location: 9 X G c-<�© ri C roperty Owner: i� � r k-A 1 J i g Subdivision Name; Mailing Address r2 9 40' 45—Md City/Town: 127e4. City/Town: e°U/�JX- Z/1 / Gr/ 177A' m G: Assessors Map 7 Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no streetaddress.av ilable .. c Y Board of Health permit obtained: Yes Not Required ❑ Permit Number Date Issued 2. W K PER�OFiMER 7;,.7- ;_ 3. PROPQSED USE'777T , * OF'TTING METHOD . Iff New Well ❑ Abandon El Deepen El Recondition ❑ 'Re lace ❑ Other ❑ Domestic rrigation El Monitoring El Municipal ❑ Industrial ❑ Other ❑ Cable ❑'Auger C%� A r Hammer - ❑ Direct Push ❑Mud Rota ❑ Other 5.4V W,L,OG'._ "� � Unconsolidated Consolidated S1 :SKltT%H uae pnrmaaaai lenamarka Ylth; iltl aoi a) From (ft) To (ft )s Permeebll Hash iry uow � u w � n � a Other Rock Type (L o lk tw`-��/ to d a G 7.WELLC044TRUl;1`1QN" _ " Total Depth Drilled � Date Drilling Cc plate i From ft ) g Type O () To (ft) T e and Material Size O.D. in Well Seal Type G7 3-0 ---Casing 9,SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10, FILTER PACK / GROUT! ABANDONMENT MATERIAL „' (1 ADDITIONAL WELL INFORMATION From (ft) To (ft) Material Description Purpose Developed? ❑ Yes ❑ NoFracture Enhancement? ❑ Yes ❑ No Method Disinfected? ❑ Yes ❑ No 12; WELL,,TEST RATA`(PRQQUCTIQN WELLS) " 3."STATIC vVAT R LEVEL (ALL WELLS) ; Yield Date Method (GPM) Time Pumped Drawdown to Time Recovery to (hrs & min) (Ft. BPGS) (hrs & min) (Ft. BGS) Depth Below Date Measured Ground Surface (FT) o S � c�eo;tr 6 ,can r>7 F l `" 7— % 14. PERt1ANENT RUMP (IF, AYAILABLEj - ;; "�, 15 NA�E(AARRESS OF PUMP INSTALLATION CONIPANY Pump Description a / Pump Intake Depth 00 (ft) Horsepower Nominal Pump Capacity (gpm)E7• Z 4,# 16 GQI[IMENT�S 77 WALL D t1 JIL R'S S1a17(3N1Et,4T y � Driller: ✓ l s!� c` d.- Firm: ` VLZE -1 This well was drilled and/or abandoned under my supervision, according to applicable rules and regulations, and this r p6rt-)s cy late and correct to the best of my knowledge. Supervising Driller Signature: ' �f Registration #: Date: � CP 6 ` Rig Permit #: I I / I ePI-3� NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion. COP! BOARD OF HEALTH