HomeMy WebLinkAboutPark St. #36 - 5/18/2015APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: t Ly h I—K � ` , Telephone 3 59 _ 7 1'i 7
Location: 3(' r
Registered
Well Driller: (f. 1 Em Imn :i-, MA Lie #
Address:
TYPE OF WELL:
Domestic Potable (for household use)
—T 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 $75.00 Industrial/Commercial $75.0�0' } Agricultural $75.00
Date: �} 1 i I Applicant Signature: ., (( to e
The above appli
following use at
and permission is granted to drill a well for the
omestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human coi
Industrial/Commercial Auxiliary (for manufa(
_ Agricultural (for irrigation of land in the'busi)
Date: Approved by:
on, including food processing)
etc.)
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
261-7330 to be added to well list.
Massachusetts Department of Conservation and Recreation
Office of Water Resources
TYPE OR PRINT ONLY i' 910 CompOetp®n Report
I1. WEL! LOCATION GPS (Required) North 6 �, Ca _ West Z 1 ° _ a h -
Address at Well Location: -LSD
/`R/1/(
S < Property Owner/Client: ul}/1'G•- -(- 4 -
Y, S'
Subdivision Name:
Mailing Address: 26 4 /9
.'
& �
City/Town: e�%fl/t SFiG
Zd IWA
Citvfrown: n "5' f /-J
141191 t
Assessors Map Assessors Lot #:
NOTE: Assessors Map and Lot # mandatory if no street address ayailab e
Board of Health permit obtained:
Yes El`�
Not Required ❑ Permit Number
Date Issued
`. WORK PERFORMED d , WELL" TYPE
4n matt t snte nn�;ear,r
�� ncA�„
j q(/
N Ov�erjburden Bedrock
( From (it) To (ft) Type Thickness Diameter
3 A(cLL Lt?G
�I__ ` �,
OVERBURDEN
L 11HOLOGY
t Water
B
Zone
Loss or
Addition
of Fluid
Drop in
Drill
Stem
Extra
Fast or
Slow
Drill Rate
Li Li Li
,
❑ El ❑earing
;From (ft) To (ft)
Code Color Comment
j7 SCREEN
d
<
I
%Z'o
Y !
Y / 1
F /
,From (ft) To (it) Type Slot Size Diameter
A e)
Y16D
Yl .I
F!
N
I
I
Y/ N
Y/ N
F/ S
y a ANNULAR SEAT_/FILTER PACK/ABANOONMENP MTi
Y!N
I Y/N
F/S
From (ft) To (ft) Material Description Purpose
I
I
I Y I N
Y/ N
F/ S
Imo-
I
YIN
Y!N
F I S
4
❑❑
❑❑ it
Y/ N
Y/ N
F/ S
::10
1:1 El
�1 }Isr"L?.S3G;
BEDROCK
Y/NIY/N F/S
Water Drop in Extra bra Visible
Bearing Drill Large Fast orslovi Rust
Zone Stem Chips Drill Rate Staining
❑❑
ElE
Loss or
Addition
of Fluid
`(! N
I N
Y/ N
Y/N
Y/NYF!S
Y / N
Y/N
Y/ N
of II
Fracturesl7
per foot
j
p
9' SITE E SKETCH
LI T HOLOG'1
{ S
l
5((
lj
Fj
(� j
It
From (it) To (it)
Code
Comment
I
1' / IV
`Z / N
F/ S
Y 1 N
Y/ N
Y/ N
F l SIY
/ NIY
Y/ N
Y/ N
F/ S
Y/ N
f
Y/NY/NIFIS
Y/N
YINYIN
FIS
Y/N
YINY/N
Y / NY
/ NIF
/ SIY
/ N
IY/NY/NF/SIY/NYlN
Y/NY/N
F1S
Y/N
=�._
Y! N
F/ S`
// N
S%
1_0__WE! TE: T DATA (ALL SECTIONS MANDATCRY FOR PRODUCTION WELLS) --
11. STATIC WATER LEVEL (ALL WELL S)�
j Yield Time Pumped
Date iMethod GPM his 2: min
(GPM) (
Pumping Level Time to Recover Recovery
Ft. BGS
) 1 ) (his l4 min) (Ft. BGS)
i Date Measured
Depth Below
C,round Surface (ft)
i
I
AVAPLASLE)2. PEnMmENT PUMP 11 !PDDt
tONALWL INFORMATION
_
Pump Description Vr 91 7F ❑ Horsepower— -- iDeveloped
;Pump Intake Depth'SvtRi412e (ft) Nominal Pump Capacity ZL3 (gpm)
/ N Fracture Enhancement Y /
Disinfected/ N Surface Seal Type
Total Well Depth Depth to Bedrock
d".'' COMViENTS
j
r o. vver_� wFuLLEN a a r A r =bitty I q I nis wen was aneea, altered, and/or abandoned under my supervision, according to applicable
((�� rules and regulations, and thj po s c le and correct to the best of my knowledge.
Driller: RdAl� (%✓ll�al�i%� Supervising Driller Signature: / — %Registration #:L—L�Yi
L�J
Firm: % dP i R-�• Date Complete: / .Rig Permit #: I I it J'� 91
I
NOTE. rAW1 Completion Reports insist be filed by the registered well driller within 30 days of well completion