HomeMy WebLinkAboutOld North Tr. #46 - 4/6/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name /%er,6✓ / I _/_ %WI'll .ic_/ 03.'?7-%
OLD _
Address [Zki✓t�r�it
Location
Registered
Well Drilh
Address !; i�y,� i� ��� n Yr✓ n! z r.? � . r
TYPE OF WELL
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)
Fee: Domestic $ 10.00 —Industrial/Commercial $ 100.99 N/C
Date: Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been
following use at yi I
permission is granted to drill a well for the
Domestic Potable (for household use)
I ;60mestic 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 �J business of agriculture)
�-t Date: - 6-0 Approved by: ed e Lam( -k p�
For the Board of Health
NOTE. Electrical permit required, underground cab ".11" ecl., ''}f'st W inspected
Upon installation of well, call Department;�ftiPublic(Works office at
261-7331 to be added to well list.
���r rflr pia
Department of Environmental Management/Divislon of Water Resources
WELL COMPLETION REPORT
WELL LOCATION
GEOGRAPHIC DESCRIPTION.
Address 4/6zn4d, e4P 44
i-
t V N S of
r4.4,�
(leerl (rlmly
City/TownA"
Well Wellowner_/�^3.�n
Address !�/(n m/,i N/�..ed /!r%�../
/j/h -N S('E-)W of.
/Il lersect. w/
r `!
Board of Health permit obtained: yeess l' no. ❑
/
j
WELL. USE -
Domestic ❑ Public ❑ Industrial ❑
WELL DATA:
Total well depth ft.
Monitoring 0 Other
Depth to bedrock ft.
Method drilledVy.Wzy e �'
Water -bearing rock/unconsolidated material,
:'
Date drilled �Z19 Zn
�o
Description rn 4/l S�/�f". GG-ua
c IT r ��r 5 �
Water -boring zones:
CASING
-.
1.) From 9 ? To
Type �
Lengthy tt. DiafLD.(- f" in.
.!
2) Front To - :9 !P/
� r
31 From _ToU �'-
-
Length Into bedrock / ft'
,.
Gravel pack well: dia.
jProtective
well seals
Screen: dia.
i
Grout 2' Other "/%
Slot✓ length_from_to_
STATIC WATER LEVEL (all wells) .
Static water level below land surface _,L.o't_ft. Date
WELL TEST (production wells)
Drawdownfl. after pumping_
hr.— min, at gpm
How measured - Recovery
ft. after—hr. min.
LOG of FORMATIONS
COMMENTS'
Matedeb
From
To
0
Driller
r•rrFg`'�' p -.
I
_
r I
Firm T✓_n
• i ;G, �l/i / 4, ,t, %:�„e
Address
��i,,SL7,5
1
City/Town
Supervising Driller Reg.#
-
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5, yrrvlel%ig n4h(en0' I d�
i Plr.p""rr"mr BOARD OF HEAV14 COPY