HomeMy WebLinkAboutPark St. #42 - 5/15/2015APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: %/L ')�42L&jJ,, Telephone G,I 3j9 ,'&4
Location: Bgc k5a"-4 1-e + ni CZ14 -t- 0 �
Registered
Well Driller: MA Lic # 7,66
Address: (' D && K loll. S &AaYA, 6 T X, ci% 6)28 76
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: Domestic $75.00 Industrial/Commercial $75.00 TAgricultural $75.00
Date: (a , / d%h' Applicant Signature:
The above application a � en a oved and emission is granted to drill a well for the
following use at
Domestic Potable (for household use)
6omestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
_ Agric ltural ifor irrigation of land in the mess o agriculture)
Date: -ts-7 �� Approved by:
I e 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 i180p compoeggo0e
WELL LOCA i ION
GPS��-(Required) North .�� � U , y� _ West �� r ,
1
Address at Well Location: 4 ✓✓-.,j �/1tn1 le 5 — Property Owner/Client:--&-4�c+ n �r1 LGe•'t/
Subdivision Name: Mailing Address: c;L P/r' $
/
City/Town: Z 7 /a /1 i' /-'i' t //I/� City/Town: /11 Yf.-Set:7 , t L cl lit-ir
Assessors Mao Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address vailable
Board of Health permit obtained: Yes ]R' - Not Required ❑ Permit Number Date Issued
?.'UVORK PERFO RkfiED
S, i11PI L TYPE
n. DRILLING VOETHOD
S. CASING -- '
%Overburden I Bedrock
R31FA
I — y
From (ft) To (ft) Type Thickness Diameter
15F El El
I
Li Li ❑
(_S. Ii1/E LL LOG it
OVERBURDEN
Water Loss or Drop in Extra
( Fast
❑ ❑ ❑
LIT;-IOLGGY
Bearino Addition Drill or
Zone of Fluid Stem Slow
i.
11 SCREEN
From (it) To (ft)
Code Color Comment
Drill Rate._
i
Ci
CL�1
rrJ u't
�11�
Y /2
Y / 1
F /.
From (ft) To (ft) Type Slot Size Diameter
o� b..;i'
��1 _
�
li
C.:S
�'J
lbo
Y / I ,
Y / N�
/
t
—F
. 8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL I,
Y / N
(Y/N
Y / N
Y/N
F / S
F/S
!From (ft) To (ft) Material Description Purpose
Y/N
Y/NI
F I S
j�—
❑❑
❑❑
IY/N
YIN
F/S
I[
❑❑
I
Y /NIY / N _F / S
h
.❑❑
❑❑ ❑❑
UVEL="Of ,
BEDROCK
Water Drop in Extra Visible
Bearing Drill Large fasterSloiv Rust
Zone Stem Chips Dnll Rate Staining
Loss or
Addition
of Fluid
g of r
Fractures;
per foot.
_
9• SITE SKETCH
-
LITHOLOGY
!I
t
;From (ft) To (ft)
Code
Comment
/ N
Y/N
I il�C'
r
�/ fi
Y/ N
Y/ N
F/ SIY
/ NIY
'I
Y/N`(/N
F/SIY/N
}
Y/NY/N
F/S
Y/N
Y/N
Y/ N
Y/ N
Y/N
Y/N
I
R j j
IY
/ N
Y/ N
F/ S
Y/ N
IY
/ N
Y/ N
F I S
Y/ N
Y
Y/NY/N
F/S
Y/N
Y/NY/NF/SIY/NY/N
I ` -19YIN F/S Y/N
--------`//NIl'/N�F/S
-L
Y/N
Y/N
tiI /
`=L u T
CAi'A (ALL Ss ,IONS MANDATORY
FOR PRODUCTION INELL.S)
--
11. STATIC
WATER LEVEL (ALL WELLS)!
Yield Time Pumped Pumping Level Time to Recover Recovery
I�
Depth Below j
'i Date Method (GPM) (hrs &, min) (Ft. BGS) (hrs & min) (Ft. BGS)
! Date Measured
Ground Surface (ft)
-
6
I
I
'-s-9 iafERMA n r
¢;_MT PUMP (IC AVAILABLE) - I73.
ADDITIONAL WELL INFORMATION
;I Pump Description X Wr lt-❑ Horsepower 3
Developed Y / N Fracture Enhancement Y / N
i.
Pump Intake Depth 50Afe7lca (ft) Nominal Pump Capacity e-' m
(gp )
Disinfecte Y / N Surface Seal Type ® ®❑ !
°`'." COMMENTS
Total Well Depth Depth to Bedrock
1-15. VIELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision, according to applicable
rules and regulations, and 1iierre!!65 is co le and correct to the best of my knowledge.
�/i l—may
Driller: r ./'�1i�in s- Supervising Driller Si nature - a
i P 9 9 -�•-�-Registration #:! I �I d l
�,— _
Firm: raj, Z 5 ,��..All-� .izsD �/iS' y��� Date Complete: 6 /.� //✓,' Rig Permit # 31 1
1v07E. Well Completion lieports mast be filed by the registered well driller tvithin 30 days of well completion.