HomeMy WebLinkAboutPlymouth St. #50 - 8/29/2005TYPE OR PRINT ONLY
Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITU����DE
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Address at Well Location: Property Owner:
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Subdivision Name 21' "" /`I 4ed fi"''; 1 1'
Mailing Address:
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City/Town: a rQn S City/Town:
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot It ma J IoWqV& OrTt"s$l ailable
Board of Health permit obtained: Yes ❑ Not Required Permit Number Date Issued
2. WORK PERFORMED
3. PROPOSED USE
4. ORI
❑ .Cable ❑'Auger
El New Well El Abandon
❑ Domestic02f Irrigation
❑ Deepen ❑ Record tion
��F �o /o �d
El Monitoring ❑ Municipal
FfAir Hammer ❑ Direct Push
❑ Replace ❑Other '�
❑ Industrial ❑ Other
❑ Mud Rotaty ❑ Other
5. WELL LOG
OC
Unconsolidated
Consolidated
-6. SITE
SKETCH (use permanent landmarks with distances)
W
Permeability
I
From (ft)
To (ft)
High
Low
a
m
Other
Rock Type
�ICx,
�
W
7. WELL CONSTRUCTION
8; :CASING
'
Total Depth Drilled S x
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drillin i. Complete
0 , j
/ C
9. SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL .' 77'11.
ADDITIONAL WELL INFORMATION
Developed? ❑ Yes r No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes M `No
Method
Disinfected? En Yes ❑ No
12. WELL
TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL
(ALL WELLS). j
Yield Time Pumped Drawdown to Time Recovery to
Depth Below
Date Method (GPM)"' (bra & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date easur d
Ground Surface (FT)
14. PERMANENT PUMP (IF
AVAILABLE)
15. NAMFIADPRESS OF PUMP INSTALLATION CQMPANY
Pump Description ° ��'""(s `I1, Ic- Horsepo r
l 1/ S t� rt i (er vo r i
-f L.
Pump Intake Depth � t (ft) Nominal Pump Capacity
16. COMMENTS
17. WELL DRILLER'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: 6 f Supervising Driller Signature: Registration #:
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Firm: ° Date. Rig Permit #: 1 1 1 1 1
NOTE. Well Completion Reports Hurst be filed by the registered well driller within 30 days of well eompletion.
BOARD OF HEALTH COPY