HomeMy WebLinkAboutOld North Tr. #45 - 9/16/199709/10/1997 13:11 5082617343 TOWN OF MANSFIELD
-`;GE 01
All PIj(: 110N Fn$1V&MT TO DRI t L WFLL
Name
Addrey;__
A,cirires4� .�i���-l'h A� . �1{anl-1( J.L.L.Q.,�LL—�t:.4�., �u•�—� - -- —..._ ,
,nTE OF WELL
`IJdti'iestic Potable (for household use)
ionx-estic Auxiliary (for watering, pools, etc.)
Ind► striai/Commercial Potable (for human consumption, includin;,r food proctxcsing)
_Iudustrial/Commercial Auxiliary (for mamtfacturing, etc.,`.
,_ Agrianinit-ai (for irrigation of land in the business of agric inure)
Fee: Domestic 5 I0.00 Iadustrial/Cotttmercial $ IM00 tLM� Agriculi trnl
Date:Applicant Signature:�
PERMU TO DRILL A wvi., ,
The above application has been approved and permission is Slanted tc: drill a well far the
following use at --
--,Pomcstic Potable (for household use)
omrstic tuimit - ary (for watering, pools, eti:. j
,InduEtnal/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for mamufteturing, etc.)
�Agritlturai (for irrigation of land in the business of agrica lture)
Date:, �,�' Approved by:
For the Board o;'FIeril h
NOTE" Zlecnzral parrnit required, underground cable o-era h trust be inspeetpc
.� Departments of Environmental Management/Division of Water Resources
6:N
WELL COMPLETION REPORT
WELL LOCATION
GEOGRAPHIC DESCRIPTION
Address y�., li,lJ1 ✓ya�ih�a ' /
.
N S ( W of
�mle)L
)
Well owner
Address/;— _�r< ✓ 1�
)/0 r N 6)E W of
9
(mi. M tenths) (circle)
Board of Health permit obtained: yes EII'no ❑ intersect.
(road)
WELL USE WELL DATA ,
Domestic ❑ Public ❑ Industrial ❑ Total well depth ,Soft.
Monitoring❑ Other )5 I Depth to bedrock /ot ft.
Water -bearing rock/unconsolidated material:
Method drilled
- - Description
Date drilled Water -bearing zones:,
CA �
SING y //
Type /'2 6t , it' /
f) From yD To .S'o
2) From 1GA2 r To / 20
Length.Mft. Dia(I.D.) in.
3) From
To
Length into bedrock—ft.
ft.
Gravel pack well:
dia.
//
Protective well seal: n40 MI P_
dia.
Screen:
Grout ❑ Other rt t'
Slot# length
—from —to_
STATIC WATER LEVEL (all wells)
Static water level below land surface I�
_
ft. Date-1UL�__/
�� /
19rY
WELL TEST (production wells) T_
Drawdown_50 ft. after pumping J4 hr.-0 min. at gpm
How measured _..,L-r Recovery _.1196 ft. after ?. hr.0 min.
LOG of FORMATIONS
Supervising Driller
BOARD OF HEALTH COPY
I
t