HomeMy WebLinkAboutOld Stable Dr. #7 - 7/9/1999APPLICATION FOR PERMIT TO DRILL WELL
Name
Address
Location
Registered
Well Driller
TYPE OF WELL:
- yDomestic Potable (for household use)
4/ 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. /C Agricultural
Date: . ' ! Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well for the
following use at �7
Dome tic Potable (for household use)
L-D-0-mestic Auxiliary (for watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
_Industrial/Commercial Auxiliary (for manuZor
g, etc.)
_Agricultural (for irrigation of land in the f agriculture)
Date: O _ If 2 ' �1 cl Approved by:
Board of Health
NOTE: Electrical permit required; underground cable trencl: must be inspected
Upon installation of well, call Department of Public Works office at
261-7331 to be added to well list.
Department of Environmental Management/Division of Water Resources
WELL COMPLETION REPORT
WELL LOCATION - t1 - GEOGRAPHIC DESCRIPTION
Address 2 �6Ib S1'R ), P".
N S E W. of
(feet) (circle) -
City/Town _; MA
Well owner kohe,i ��Q 1.S k (road)
Address 2
-N S E W' of
(ml In tenths) (circle)
Board. of Health permit obtained: yes no ❑ Intersect. -w/
_ 1 (road)
WELL USE WELL DATA ,
Domestic [ Public ❑ Industrial ❑ Total:.weli depth'ft.
Monitoring❑ ..Other Depth to bedrock.. ft
Water -bearing rock/unconsolidated material:
Method drilled_ Description
Date, drilled��y- g 1 Water -bearing zones:
CASING I -7 ' 1 j,From 2 h To yn
Type / , Is.4� 2) From To
.Length. ft.Dia(I.D.) p6 in. 3) From 'To -
Length Into bedrock p1) ,nfi. Gravel pack well: - dia.
Protective well seal: t cc4,i Y^v" ' tlia: '
1 Screen:
Grout ❑ Other Shoo, Slot# lengthfromto:'.
STATIC.�WATER LEVEL (all wells) -7 /
Static water level below�land surface 3 S'. ft. Date 21_- ,2 /9X
WELL TEST (production wells)'
if,
Drawdown ) o v. -ft. after pumping � hr.. 6 min.at /0 gpT
How measured Ge�Recovery ft. after hr.021- min
LOG of FORMATIONS- COMMENTS il,-
Materials - From ,:To-- - _?
p
- Driller , 4IJ /
AL 70
t
,qp Firm
Addressf6ADX-
6City/sown <:-.-k,,4-1� Iln
Supe/rvi)sing Dfulle�r Reg.#
'f Signature of supervising registered well ddller
r, Please print firmly. - -
I - - BOARD OF HEALTH COPY