HomeMy WebLinkAboutPilgrim Rd. #14 - 6/30/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name y"I L -_rOC, 9 LE
Address
Location & �o S�
Installer 1) is
TYPE OF WELL:
�o/- -333- 0&=3y
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_Domestic Potable (for household use)
�/bomestic 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
Date: 61309-� Applicant
PERMIT TO DRILL A WELL
The above applicatio ha en approved
following use at JW
is granted to drill a well for the
_Domestic Potable (for househc'.;i use)
*—Domestik, Auxiliary (for watering, -pools, etc.)
Indtis,rial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: �- �_ Approved by:
"he Board of Health
NOTE: Electrical permit required, underground
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Department of Environmental Management/Division of Water Resources
WELL COMPLETION REPORT
WELL LOCATION GEOGRAPHIC DESCRIPTION
Address /-rL, i �Q W is:s Fi
_ N SOW of
.feel.
Clty/Town' ..12/srlr c' �'.' r 1 lolrtlel
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Well owner t- !CI // Z-��r�" '4!o dl !1f
Address._ /L/ %ir� P. N -S Il(* of
mprlT
-B(Iard of Health permit obtained: yes es. no ❑ infersecr. W E21
lroedl
WELL USE I WELL DATA rt
- Domestic ❑ Public❑ Industrial ❑ Total well depth, S'Oi ft.
-- .Monitoring ❑ O�/ther .Depth to bedrock' {t;
Method drilled ed i ��. of ,_f Water-bearmg rock/unconsolidaled material;
i Date drilled �'�3t//9 7 Description (r'+.-r-e..
CASING Water -bearing zones:
TYPe ,I�j"Y>,CL— / 3 Length 1) From i/�' '> r To /.�.�
! ZI From .7_ Tot'
Length Into bedrock ar Jft 31 From To. 'if.'.Z
I. Gravel pack well: dia.
Protective well seal' -
Screen: dia,
Grout_ Other6 �- Sloto length_from_to_, j
STATIC WATER LEVEL (all wells)
�• -Static water level below land surface / (o ft. ale /r g �/g�
D
WELL TEST (production wells) -/)/0"t
Ljrewdown ft. after pumping _hr._ min. at gpin
How measured Recovery ft. after_hr, min.
LOGof FORMATIONS ` COMMENTS
��JJ II gq
t Melerlelt Franr 40' ( Jr^'LL KEN/, Gi bap tML�3 1�i°.r� A .
1
f ,�, Driller �/Hf �hi^cfinl/X
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Firm /=,uS/z t-�r� �✓( �� r I
Address 5 '% /-J "e i Yi/ /�f/ 4' � City/Town�uas��r"_,y_rv_i,.�_rV i'i ">• ��
Supervising DrillerlRegA
nYb4"'P -5 g1siderd wel/driller i
•PnnN rmlV ,. ` ail
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