HomeMy WebLinkAboutOld Stable Dr. #51 - 12/5/2001MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name 6 C5_�
UD
Address 1:57 ozid S1_*& G5 sell/ -
Registered
Well Driller
Address 7,1)�o S% P&LZ- 57*Z- % /i/V - s1tiC � T/��/G'Z✓� 1 1� Q / Co
TYPE OF WELL:
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: XDomestic $ 10.00
Date:
Industrial/Commercial $ 100.00
Applicant S
PERMIT TO DRILL A WELL
N/C Agricultural
The above application has been approvedAn4ermission is granted too drill a well for the
following use at
Domestic Potable (for household use)
_�:;60mestic Auxiliary (for watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
_Industrial/Commercial Auxiliary (for manufacturing; -etch)
_Agricultural (for irrigation of land in the business of agriculture)
Date: 'z'� In Approved by:
Fo the oard of Health
NOTE. Electrical permit required, toiderground cable trench must be inspected
Upon installation of well, call Department of Public Works office at
261-7331 to be added to well list.
Massachusetts Department of Environmental Management ® �q
Office of Water Resources & g
TVPF rfifa PRINT nNI Y Well Completion Report
1,;W4'LOCATION (OPTIONAL) ` LATITUDE = 0 ITUAE,
,_;BPS,
Address at Well Location: � ? QUI) o%i)YN.t Irk ' Property Owner: G It L (-, � I/o'))(o o 1
Subdivision Names Mailing Address:
CitylTown: / r� } l i i (�-i tl > City/Town: Eli ryv')�" (> w
i
Assessors Map Assessors Lot #:'- NOTE: Assessors Map and Lot #mandatory if no street,address available
Board of Health permit obtained: Yes El Not Required ElPermit Number Date Issued r ^ ' )�
f±OFOSEO.(1S„
❑ Domestic ❑ Irrigation
�v.
❑ Cable ❑ IAuger
Cable
New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
O' ❑ Direct Push
❑ 'Re lace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rota ❑Other
'
F
Unconsolidated
Consolidated
ifi $Y : � _ uxap� in�nenl Jandmerko with at'stances). -
Permeability
«
From (ft) To (ft)
R
High
Low
N
O
N
R
cv
a
o
m
Other
Rock Type
G'P
7:;11VELLCONST,RUCTiQN:..,.':r8.�ASIN�i
?� _�"r
Total Depth Drilled LTO
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
_
Date Drilling Complete -
0I
9.SCREEN
From (ft) To (ft) Slot Size Sere nType and Material Screen Diameter
10, FILTEPtPAC, (- C,ROUT',1 ABANDONMENT MATERIAL
f 1.,AUAl7lONAL WELL INFORMATION
_ ,.
Developed? ❑ Yes ❑'No
From (it) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes ❑- No
Method
Disinfected? ❑ Yes ❑`No
12 WELL jESTDATA,(RFtOpt)CTION N(ELLS}
�v TATIO WATER LEVEL, (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Depth Below
Date Method (GPM) (hrs & min) (FL BGS) (hrs & min) (Ft. BGS)
Date Measured Ground Surface (FT)
14; PERINAN) N f PI1MP:(�F AIIAILAHKI )`
fS (AtAFJAOUHESS`OF PUW111STALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
18r`COMMENTS
1TJNEIL,I F{I L SST/ ENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this raep is complete an correctttQ,the best of my knowledge.
Signature: 1 iei�istration #J I ?1 216
�L�h� )� ; I %t'i 1
Driller Supervising Driller ���
j d - �'��� ��—Riq Permit #: Lh' I I I
'�.% 1 )1�Yl� �L (�(IL �l_�i.
Firm 1 }��T 1 Date:
A & W ARTESIAN WELL CO,
Date -Seol— a
Namel�ts'
Mail Address Lo 5 ry8L6_— Or2r uG--
_
Well Location Lot # Pole #
✓e�—