HomeMy WebLinkAboutPratt St. #399 - 7/16/2003--Z �,,o r1 5
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name L/b &Cu/ Onfx/-/
Address: �� /��/y% % �T Telephones�S - �'2
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Location:
47
Registered
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Well Drill
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S W K S MA Lie #
Address: c" -j
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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 $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: 7Zl(,O Applicant Signature:,
PERMIT TO DRILL WELL
The above application has
following use at "� c
and permission is granted to drill a well for the
_ Domestic Potable (for household use)
1, 1 omestic Auxiliary (for watering, pools, etc.)
_ hndustrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the busi ess of agricul re)
Date: th o ?,. Approved by:
For 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.
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TYPE OR PRINT ONLY
Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE `-
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Address at Well Location: .f ,) 0 ' - Property Owner. _ �!
Subdivision f/��)m))e k Mailing Address. ,Jjk
City/Town: / / 7//% � /i� t.�-( - City/Town )/ ' �. _ , o-;t ( L
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes W, Not Required ❑ Permit Number Date Issued
2. WORK PERFORMED
3. PROPOSED USE
4, DRILLINGMETHOD
New Well ❑ Abandon
❑ Domestic gy Irrigation
❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
Egg Air Hammer ❑ Direct Push
❑ Replace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rotary ❑ Other
5. WELL LOG
From (ft) To (ft)
M
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Unconsolidated
Consolidated
6. SITE
SKETCH (use permanent landmarks With distances)
Permeability
High
Low
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Other
Rock Type
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7.rWELL CONSTRUCTION :;
8.,CASING
Total Depth Drilled /,,t,
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete
.....
, -
9. SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK 1 GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
..... _..
Developed? ❑ Yes We
From (ft) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yes No
Method
Disinfected? ❑ Yes VNo
12.WELL TEST DATA (PRODUCTION WELLS) ! 13.<STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS' '.
17. WELL ORILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is complete and correct to the best of my knowledge.
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Driller � /�e, (- �Ll�,
�Supervising DrilleX,Signatur ��P,�1�—{%Registration # .C�' -J (/� Date: �/ / (/ —RioPermit #:
Fir(n:
NOTE: Well_Completion Reports must be filed by the registered rvell chiller rvitbin 30 days of ivell completion.
BOARD OF HEALTH COPY