HomeMy WebLinkAboutMichael Ln. #8 - 8/6/2002V*/V0/9VV9 iun 14:V4 rnA DVO zoi "14ZD rurrn UP' NAivsr'tLLu 10002/002
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address:
Location: \ T\ r,
Registered
Well Driller.
Address:
TYPE OF WELL:
WCa
_ 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: ----Domestie $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: (q —6—C)Z Applicant Signature--
PERMIT TO DRILL WELL
O19")3
The above application has been approved and permission is granted to drill a well for the
following use at ll,w.MY
_ Domestic Potable (for household use)
✓Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for In ufae ,etc.)
Agricultural (for irrigation of land in the bM
agriculture)
Date: � Approved by: —_
F the Board of health
NOTE: Ekclrkal permit required; underground cable tenck muse be inspected
Upon Installation of well, call Department bf Pubtic Works office at
261-7330 to be added to well list
• Environmental Drilling
• Groundwater Monitor Wells
• Structural Borings Logs
June 18, 2003
Mr. Tim Sjoberg
8 Michael Lane
Mansfield, MA 02048
RE: Errors on your well completion report
Dear Mr. Sjoberg;
Cola ec::i O w(? � ( C.
Re- por-r �
�)'O�q(o
I want to apologize for the mistakes that were made on your well completion report.
Unfortunately it was clerical errors made by the office.
)rilling
xoved Training
1) Mailing address information was taken off your deposit check
2) # 11 Hyfrofrack, we did not have the report back so office was not aware of track
3) # 14 Horsepower was a clerical error, but the pump description indicates 1.5
horsepower and that is what is in your well.
I am sending a revised well completion report along with this letter to the Board of
Health Agent and the state with all corrections made.
Please accept our apology and we hope this did not cause you any inconvenience.
Drilling Services, Inc.
Sibley
Cc: BOH Mansfield
Mass Dept of Water Resources
Largest Hollow Stem Augers in New England
P.O. Box 353
Westminster, MA 01473
(978) 874-0071 • FAX; (978) 874-1549
www.americandrillingservices.com
Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well corvtipletion Report
COPY
120896
-`v WELL
7. WELLLOC
LOC__ ATt<>,J GPS (OPTIONAL) LATITUDE _. LONGITUDE
Address at Well Location: - Q__MLC. !R e- / Lctn &- Property Owner: P-T ryl
Subdivision (Name Mailing Address: _S1-114YC
City/Town:City/Town:
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot If mandatory if no street address available
Board of Health pownit obtained: Yes Not Required ❑ Permit Number Ni'4 Date Issued ,30 -0,1
2: WORKPERF'OIRNIFED -
3. PROPOSED.USE
4. DRILLING METHOD -
( . New Well 1-1 Abandon
El Deepen I.] Recondition
❑ Re lace ❑ Other
_
❑ Domestic PS�'Irrigation
El Monitoring ❑ Municipal
❑ Industrial ❑ Other
❑Cable El Auger
Air Hammer ❑ Direct Push
rx ❑ Other
6. WELL LOG
G:
Fll
7
Panneahilily
Unconsolidated
v
in
m
>
0
m
�
D
m
Other
Consolidated
Rock Type
_
6. SITE'SKETCH (use permenont Jandmarks with distances)
r'O�ISL
WCII
-••—
From (ft) To (ft)
High
Low
ED, /Zac
_
7.WELLCONSI,
- "trCf1O1V
$. CASING
Total Depth Drilled _-18 ) t
Date DrillingComplete
/ '
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type )
e.,� n tye
(
ei
D. SCREEN
From (ft) To (it) Slot Size Screen Type and Material Screen Diameter
10. FiiaCit PACK i GROUT I ABAND014MENT MATERIAL
1'l. ADDITIONAL WELL INFORMATION
Front (ft) To (i?) Material Description Purpose
_.._�_
Developed? �es ❑ No )
Fracture )
Enhancement? f?<Yes ❑ No
Method n)
Disinfected? Les ❑ No
7—
t'`
_
- _
12. WELL TES Ilvr l;a (PRODUCTION WELLS)—
_
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Date PAetY oil (GPlvl) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Depth Below
Giound Surface (FT)
W-yam I�� nC�
14. !'ERMtriULlVl' Y-1iU(!! (il= ikVs:ILA1�LE) -
03
15, NAMDIADDRkSS OF PUMP INSTALLATION COMPANY
r
Pump Description ��' G 5 /,5 y/off Horsepower;L
Pump Imake Depth( !�&C— (ft) Nominal Pump Capacity /d (gpm)
S `J ` r r� .�•
COMMENTS 9 )
17. WELL DRILL f: WS STATCMFN'r� This well was drilled and/Oibandoned under my supervision, according to applicable rules
and regulations, and this pq is com lete and correct to the best of my knowledge.
Driller:✓✓'' T I "z �� tL✓y 1 Supervising Driller Signatur /_f �� Registration #: 1 )
Ftrm:fTi1.'L.�.. �i" �� t • ��i7//!'c S TAG Date: �t7,t C,�/l%'h Rig Permit #: -
NOTIi: Rell Completion Reports must be filed by the registered well driller within 30 days of well completion,
nif:"i I rr3 f t^la`f
Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Deport
1. WELL LOCAT,JP _a. GPSW(OPTIONAL) " LATITUDE LONGITUDE _
Address at Well Location:8(Y)lr'h a( - n e- Property Owner: S v ei'u
Subdivision Name: Mailing Address: // i :61-ICL
City/Town: 12 8,N1 ' � Z l U City/Town: j(A�lNS
Assessors Map __ Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes Not Required ❑ Permit NumberIVI " Date Issued R.36'U
�.r
2. WORK PERFORMED
3. PROPOSED: USE "
4..DRILLING 'METHOD '..
1�& New Well ❑ Abandon
IED
❑ Domestic Pi��'Irrigation
❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
Air Hammer ❑ Direct Push
I
❑ Replace _❑ Other
Industrial ❑ Other
PS�.Ndud Rotary ❑ Other
5. WELL LOG r Ir Unconsolidated Consolidated 6.'SITE SKETCH (use permanent landmarks with distances)
d W Permeabrily
� oa
From (ft) To (It) High Low O U) 10 m Other Rock Type
a V, t/ `�3loncq-Df,JZ
` 5
150 }
_ No�sc
)Vve
7. WELL CONSI'FNJCTiON 8. CASING,
Total Depth Drilled __5EL(L) From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete
9.SCREEN
From (ft) To (f1) Slot Size Screen Type and Material Screen Diameter
`IO. FILTER P WC /GROUT / AEANDONl MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? L�Yes ❑ No
From (ft) To (ft) Material Description Purpose
6 Fracture
Enhancement? ❑ Yes P No
Method
Disinfected? LeI' es ❑ No
12. WELL T EST OA IA (PRODUCTION WELLS) 13.;STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
at L'Q;fa j0 y ham _ Q G / Vl -�2 9 -03 c li
14. PERMANENT PLIOAP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description{'J`-s/,`� N/ Horsepower /'
Pump Intake Depth (ft) Nominal Pump Capacity jd (gpm) 3T ` S
16. COMMENTS
ll was drilled and/o bandoned under my supervision, according to applicable rules
17. WELL DT2iLLER S STA1"EtvYENT7andregulations,
and thi r pq is complete and correct to the best of my kln�o1wledge.
Driller: T1f 1 (i �� i.[ 2i1 SupDriller Signatur Registration #: IL
Firm:�,t//'� //�i7.S�TIi/CcS 1lJG Date: �1�0" Rig Permit #:��)
MOTE: M11 Completion Reports must be filed by the registered well driller within 30 days of well completion.
DRILLER COPY
Massachusetts Department of Environmental Management
Office of Water Resources 1-20896
TYPE OR PRINT ONLY Well Completion Report
11s WELL LOCATION GPS(OPTIONAL) LATITUDE I LONGITUDE
Address at Well Location: wIg;'6,� 44R4l Property Owner: % f J4J r n 6 < r
Subdivision Name: Mailing Address:
City/Town: �tr ( l r / O City/Town.
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot It mandatory if no street address available
Board of Health permit obtained: Yes Not Required ❑ Permit Number — 7' Date Issued R 6 Y )
2. WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD '-
New Well ❑ Abandon ❑ Domestic 5kirrigation ❑ Cable El Auger
Deepen ❑ Recondition ❑ Monitoring ❑ Municipal Lit�Air Hammer ❑ Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other Mud Rotary ❑ Other
S. WELL LOG
0:
Unconsolidated
Consolidated
6. SITE SKETCH (Use permanent landmarks with distances)
h
Permeability
m
From (ft)
To (ft)
High
Low
a
o
°'
ei
m
Other
Rock Type
yS
7. WELL CONSTRUCTION
8.
CASING
Total Depth
Drilled r
r
From
(ft)
To (ft)
Casing
Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete
G
- 82
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT! ABANDONMENT MATERIAL
11.'sADDITIONAL WELL INFORMATION
Developed? Q-'�es ❑ No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? 0 Yes C) No
Method ffy� 9tr'�7r'I4
Disinfected? IIj.;'>'es ❑ No
12. WELL TEST DATA (PRODUCTION WELLS) `; I
13. STATIC' WATER,LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
_
Depth Below
Date Method (GPM) {hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured '
Ground Surface (FT)
14. PERMANENT PUMP (IF
AVAILABLE)
I IS. NAMFJADDRESS OF PUMP INSTALLATION COMPANY
Pump Description _%J t' i 5".4/ / D Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS - .
17, WELL DRILLER'S STATEMENT This well was drilled and/or; ' andoneof under my supervision, according to applicable rules
and regulations, and this' on is complete and correct to the best of my knowledge.
Driller: Supervising Driller Signatur f �/ Registration #: f-)1 1() (V I
%l �, E'r� l r; ;
BB f..F i u
Firm: — "o "— ° - e - .4 Date: rr 'G'-", RI Permit #:
NOTE: Well Completion Reports most be filed by the registered well drilld wifltin 30 days of well completion.
BOARD OF HEALTH COPY
5X1 "b1&vo,.6e1n
cY'92C.
0", 0
0,1.05
66 LITTLETON ROAD, WESTFORD, MA01886
Report Number 72966
Client:
American Drilling
P.O. Box 353
Westminster MA 01473
(978) 692-8395
Report Date: 5/12/03
Sample Information:
8 Michael Lane
Mansfield,MA
FAX (978) 692-0023 1-800-649-TEST
Sampled by: Client
Date Received:
5/9/03
Date Sampled: 5/9/03
Certificate of Anal
Test Parameter
EPA Limit
Results
Units
Total Coliform (P)
0
# 3
per100m1
Fecal Coliform/ E.coli (P)
Absent
Absent
per100m1
Arsenic (P)
0.05
0.009
mg/L
Calcium
Not Spec.
19.3
mg/L
Copper (S)
1.3
<0.02
mg/L
Iron (S)
0.3
# 0.40
mg/L
Lead (P)
0.015
<0.001
mg/L
Magnesium.
Not Spec.
1.6
mg/L
Manganese (S)
0.05
0.05
mg/L
Potassium
Not Spec.
0.7
mg/L
Sodium
See Note
8.9
mg/L
Alkalinity (S)
Not Spec.
77.0
mg/L
Ammonia-N
Not Spec.
<0.03
mg/L
Chloride (S)
250
4.3
mg/L
Chlorine
Not Spec.
<0.02
mg/L
Color (S)
15
2.5
CPU
Conductivity
Not Spec.
146
umhos/cm
Fluoride (S)
4.0
0.4
mg/L
Hardness
Not Spec.
55
mg/L
Nitrate-N (P)
10
<0.01
mg/L
Nitrite-N (P)
I
<0.01
mg/L
Odor
3
0
TON
pH (S)
6.5-8.5
7.3
SU
Sulphate (S)
250
5.0
mg/L
Turbidity
Not Spec.
6.0
NTU
Sediment
pos/neg
neg
Legends:
(P)=Primary EPA Standard, (S)=Secondary EPA Standard, #=Exceeds EPA Limit,
TNTC=Too Numerous to Count, *=Background Bacteria Noted, ' = Exceeds Advisory Limit
Sodium Advisory Limits, Mass.=20, NH=250.
This water sample as submitted, has failed one or more primary EPA standards as denoted by the
# sign, and is considered UNSAFE for human consumption.
%y1V 641\
Massachusetts Certification # MA048 Mic555nnnael P. arlson, for
Thorstensen Laboratory Inc.
.,:,,,ort #: 5603143
Date : 5/6/2003
P.O.Number: 5-6-03 MC
Matrix: Water
29 Fuller Street, Leominster, ILIA 01453-4225 Client;
American Drilling Service, Inc.
P.O. Box # 353 Sample #8 Michael Lane
Location Mansfield MA
Westminster, MA 01473-
Results
Misc.
Total Coliform Present
Fecal /E. Coll Absent
This sample taken by Gerry at 1:00:00 PM on 5/5/2003.
Point of collection: Tank
Miscellaneous Scan Report
EPA Limits
There should be no Total Coliform bacteria in the sample.
Animal Bacteria
The integrity of the sample and results are dependent on the quality of sampling. The results apply only to the actual sample tested
ETR Laboiatoues shall be held harmless from any habthty arising out of the use of such results -Pagel Of
29 Fuller Street Leominster ILIA 01453-4225 (978) 840-2941 (800) 344-9977
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