HomeMy WebLinkAboutPratt St. #267 - 10/3/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name C1,1 ' S l -c-I
Address: of (a % 10✓�.,a�� `elephone
Location: ;9, 67' 2 3A
Registered ���
Well Driller:,14 L J C '�` ' NIA Lic # /0 /
Address:—�Y—
TYPE OF WELL:
_ Domestic Potable (for household use)
I/ 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 $1 0 00 N/C Agricultural
Date: /a/ Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved apd permission is granted to drill a well for the
following use atCb
_ Domestic Potable (for household use)
�/>Somestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industiial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of land in the business of a 'culture)
Date: 16 - 3-c'Approved by: iw
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.
Massachusetts Department of Environmental Management
Office of Water Resources 7
TYPE OR PRINT ONLY Well Completion Report
9. WELL LOCATION GPS (OPTIONAL) LAT TUDE LONGI UDE
�:,
Address at Well Location: r� i' Property Owner: i,
�
Subdivision Name: Mailing Address
City/Town:/f/% c%ClY City/Town: ._. ( ) ( ) U %I �J J �) ✓ _
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes ®''' Not Required ❑ Permit Number Date Issued
2, WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD
[121 New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Replace El Other
❑ Domestic Irrigation
❑ Monitoring ❑ Municipal
❑ Industrial ❑Other
❑ Cable ❑ Auger
f Air Hargmei" 1 Direct -lush
,I rrd 6t4i ❑ Othbr
5. WELL LOG
Ir
Unconsolidated
Consolidated
''-6. SITE
IPKPTCH (use permanent tart a s+witn distances)
(ft)
To (ft)
HPermeability
Q
High
Low
T
m
c
NOther
N
a
o
Rock Type
gg� !�y
G ��115From
tof(
L
/C90
7: WELL CONSTRUCTION
-
6,'CASING
77 , ,.,
77, '
Total Depth Drilled � .
Date D filing Cojnplate
C
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
-)
/
C )//r(o/� 6 <...J
L
9. SCREEN ... . �;. ,
From (ft)� To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACE{ / GROUT / ABANDONMENT MATERIA4,_
11. ADDITIONAL WELL, INFORMATION
From (ft) To (ft) Material Description Purpose
Developed? El Yes CtJ �Jo
Fracture
Enhancement? ❑ Yes Ltl40
Method
Disinfected? 0 Yes ❑ No
12. WELL
TEST DATA (PRODUCTION NIECES)
11. 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. PERMANENT, PUMP (IF AVAILABLE)
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
15, NAMEIADDRESS OF PUMP INSTALLATION COMPANY ;
16.'COMMENTS
17. WELL DRILLER'S STATEMENT This well was drilled and/or ab nconed under,(r) supervision, according to applicable rules
/ J /� / and regulations, and this redo is complete/a d correct to the best of my kno ledger
Driller: / �/� u ��/(`, ' "- Supe ing,Driller Signature: I11 (f `lY / <J( J(- Registration #: `�
/ / /ry - -. J
o Permit
Firm:.. �,% I . ( i� ('. 1, C ��Y' Date: ���/ �.� .> Rio -Permit
NOTE. Well Completion Reports mast l% filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH,-;OPY