HomeMy WebLinkAboutPark Ave. #12 - 6/21/2002MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name t 1 �JA to
Address: I2 ` /j t2 C A-u F-
Location: 61�9ys a4. /v4 G Z G 4(�
Registered .&
Well Driller: Au f_ E!M VX^ O N
Address: 67 O U E721.r-�,4 K Q
TYPE OF WELL:
Domestic Potable (for household use)
VDomestic Auxiliary (for watering, pools, etc.)
_ IndustriaUCommercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigationofland in the bus'nes f agriculture)
Fee: / Domestic $10.00 _
Date: 6 - 2 I - V .L Applicant
PERMITTO-D- RILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at �Z 2til -'
�---fi x Potabl�(;for��®us®h®Id-use)
v'IJomestic Auxiliary (for watering, pools, etc.)Co'Z`b- z oaa
_ IndustriaUCommercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
_ A icuIturaI (for irrigation of land in the_ busine s griculture) -
Date: D q�Approved by:
r the Board of Health
NOTE. Electrical permit required; underground cable trench must be inspected
Upon Installation of well, call Department of Public Works office at
261-7331 to be added to well list
Massachusetts Department of Environmental Management
Office of Water Resources 111690
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION ,.
BPS (OPTIONAL) LATITUDE ''0406mlTUDE
Address at Well Location: ' Gnu Property Owner: k
Subdivision Name: Mailing Address: %cap ?1 ✓i /��
City/Town: 44 5-Az City/Town:- ail # O c2a c
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address pvailable
Board of Health permit obtained: Yes ( Not Required ❑ Permit Number Date Issued 0`Zoa
PERFORMED
Wow
3. PFt4PQ$EO USE ` .
.DRILLING METHOD: "
ew Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Replace ❑ Other
❑ Domestic ® rigation
❑ Monitoring ❑ Municipal
❑ Industrial ❑ Other
❑ Cable uger
❑ Air Hammer ❑Direct Push
❑ Mud Rotary ❑ Other
S. W LL Lot#
fY
Permeability
High
Low
.-
a
Unconsolidated
a
cn
g
other
Consolidated
Rock Type
`6 f Sl?1:f M (use peroa anrienamarkewith 1esanaea)
fie
io /'/0 4, f
�/N r1C� t
�r'ctis.r ARC
From (ft) To (ft)
7. WELL CONSTRUCTION
&
CASING
Total Depth Drilled 7sd
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drill' n C mplete
777
t/
% SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
0 r
10: FILTEWPACK I GROUT) ABANDONMENT MATERIAL
11: ADDITIONAL WELL INFORMATION
From (ft) To (ft) Material Description Purpose
Developed? es ❑ No
Fracture
Enhancement? ❑ Yes ❑ /No
Method fe"'t-7 �rd-
Disinfected? ❑ Yes ❑ No
12,1N1 ...
TEST DATA (PRODUCTION WELLS) ' ?',
13. STATIC WATER LEVEL
(ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Date Method (GPM) '< (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Depth Below
Ground Surface (FT)
14. PE
ENT PUMP (IF,AUAILABLE)
-
1¢; NAME10DRESS OF PUMP
INSTALLATION COMPANY
Pump Description C� ` Horsepower,i &/
Pump Intake Depth 4 /, C (ft) Nominal Pump Capacity _62— (gpm)
� • � fi /�i& � % �iG« ��.
'IS COMINENTS
1T WELL ISRIIi4R'S STATEMENT' This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this rep Mis'2om I and correct to the best of my knowledge.
/s- )
Driller: f� �iG g: �I IIA161 - Supervising Driller Signature: ' - 1 d 'O I , �� 1 ~
p g g � Registration #: u�J�J
Firm: f .K� 'o r!. Date: Z2 �9 !) e?- - RIq Permit #: [--- ie J f
NOTE. Well Cou:pletiou Reports must be filed by the registered well driller within 30 days of well completion. i
BOARD OF HEALTH COPY.