HomeMy WebLinkAboutSchool St. #280 - 3/27/2007Ges,7 7/ � .? 76 -9- MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: %-- Telephone 6/%
Location: Sci-,Aoc) ( 5"7�
Registered 'L 'S
Well Driller: MA Lic # '�i grg
Address: G'i % e-/z-' /pC> zGw zeyz'
sGst �Pswi Ce,
TYPE OF WELL:
_ Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
�L Industrial/Commercial Auxiliary (for manufacturing, etc.)
„ i, ai(fork igation of land in the business of agriculture)
Fee: _ Domestic $10.00 _L,-fndustrial/Commercial $100.00 N/C Agricultural
Date: 21a 0 Applicant Signature: —
PERMIT TO DRILL WELL
The above application has
following use at
permission is granted to drill a well for the
_ Domestic Potable (for household use) l
_ Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (fyr irrigation of land in t}re busings8lof agriculture)
Date:
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 lisp
ya/- 2� s ��X
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: G U ,51czL .S / Telephone
Location-. 9 G r9rsc (/— 5
Well Driller: �i�Lf z Lr- //j'( MA Lic #
Address:
C —
TYPE OF WELL:
SLI�Tc-v�sv 'c ��'
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.)
i/gricultural (for irrigation of land in the business of agriculture)
Fee: Domestic $10.00
Date: a %
Applicant Signature:
PERMIT TO DRILL WELL
NIC Agricultural
The above application has been approved and permission is granted to drill a well for the
following use at
_ Domestic Potable (for household use)
_ Domestic Auxiliary (for watering, pools, etc.)
i adustriaUCommercial Potable (for h i
/Industrial/Commercial Auxiliary (fo
_ Agricultural (for irrigation of 1 m th busir
Date: c% - % Approved by:
including food processing)
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 Conservation and Recreation
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1.:WELL LOCATION
!GPS (Required) North West _?/
Address at Well Location: f� -Property Owner/Client Iry I�%'"`` -fir! +-�" � 'Y='n `
_
Subdivision Mailing Address
gN/a�me
/�Q I
Citylfown: CitylTown:
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes IT Not Required ❑ Permit Number Date Issued
2. WORK PERFORMED'
3. WELL TYPE
4.`DRILLING IMETHOD
6. CASING
tt /
%�ii
j'
1111H,
Overburden
From (it) To (ft) ..Type ` Thickness Diameter
Bedrock
"1
`t-1
r
El El El
5.'WELL LOG
OVERBURDEN
Bearing
Zone
Loss or
Addition
of Fluid
Drop in
Drill
Stem
Extra
past or
Slow
Drill Rate
❑ ❑ ❑
0
LITHOLOGY
7. SCREEN '
From (ft) To (ft)
Code Color Comment
%�, f5 0
j�,( (,
Y / iN�7
Y / {N)
F / S
From (ft) To (ft) Type Slot Size Diameter
C�
i f
❑❑❑
.---
(
IV0
Y/ 1)Y/(
F/S
❑❑❑
1. — — —
Y / 14
Y / {,tV,;
F / S
❑ ❑ ❑
Y / N
Y/ N
F/ S
g ANNULAR SEAL/FILTER:PACK/ABANDONMENT MTL.
Y / N
Y ! N
F / S ^-
From (ft) To (It) Material Description Purpose
Y/ N
Y/ N
F/ S`;
0
(, (?
10
IQEl
Y/N
Y/N
F/S=
❑❑
I El El
Y / N
Y / N
F / S-
❑ ❑
I ❑ ❑
Y/N
Y/N
F/S
❑❑ I ❑❑
WELL LOG
BEDROCK
Bearing
iiv(
Drop in
Drill
Stem
Extra
Large
9
Chips
Extra
Fast or
Drill Rate
Visible
Rust
Staining
Loss or
Addition Fractures
of Fluid
k of
per foot
9.SITE SKETCH
LITHOLOGY
--r --
'o!?
From (ft) To (ft)
Code
Comment
�,
r e>
l`
ry v �'`f01
Y / N
Y)/ N
(F/ S
Y /�N,Y
/(N-�
Y/(ANY/(NF/SY/(NY
r
1,
C
,�,
f�
Y/NY/N'F,YS
Y/N
Y/Nr
1 ( o
1 20
,`aN
iv
Y /4Y
/4,(E,)/
S
Y
a,,�"f,
N
N
l
i? 1,;: k
tv 0
Y / (N'
Y / (N,
(IF)/ S
Y / (N;
Y / N
u.G
U
S(
��ir, r:°- (or,.;
1 )
4�
Y./([�iY/(N
F/S
Y/(N,Y/(N
(f-
yf U
Y //N/Y
/(N)
F / S
Y /ft
Y / 1
t; riJ
5N
Y /(� }Y
/(N
F / S
Y /(N
Y / N,
10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
11. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped
Pumping Level Time to Recover Recovery
Depth Below
Date Method (GPM) (hrs & min)
(Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Ground Surface (ft)
f
}
t�
f�--
7i.w7,0
tl�
-�.
,
12. PERMANENT PUMP (IF AVAILABLE) '' 13. ADDITIONAL' WELL INFORMATION
Pump Description ❑ ❑ ❑ ❑ Horsepower Developed&/ N Fracture Enhancement(Y)/ N
PumpIntake Depth (ft) Nominal Pump Capacity m Disinfected `Y)/ N Surface Seal Type fit/ (,�
P P P Y (9P ) t,,. YP
14. COMMENTSf, On ft 6w,% Total Well Depth r Depth to Bedrock L
15. WELL DRILLER'S STATEMENT This well was drilled, altered, 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.
Driller oar° A o, �'� ' Supervising Driller Signature: y %1( 1 � � .' ` " Registration #: ( ) ir' `)
,'
r
/ I r
(t�° (. �rr 1.r`N f �: /, GI %
r P �. lete. �' RigPermit #:
Firm: Date Com
NOTE. Well Completion Reports must be fled by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
Massachusetts Department of Conservation and Recreation
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
7= J,
GPS (Required)' North -c/ _7 Y, I
West,,
'
Address at Well Location: 5' I
on: Property Owner/Client:
Subdivision Nam a:
Mailing Address:
-elzy
.
City/Town: IV'
City/Town:
Assessors Map —
Assessors Lot #:
NOTE: Assessors Map and Lot If mandatory if no street address available
Board of Health permit obtained: Yes 19
Not Required E:1
Permit'Number Date Issued
2. WORK PERFORMED 3. WELL TYPE
4. DRILLING METHOD
6. CASING
Overburden Bed —
El 09
From 0 Type Thickness Diameter
1l) 1
>11
DOE]
S. WELL LOG
OVERBURDEN
Water Loss or Drop in
Extra
Fast or
EJUEJ
Ulr�t"(
LITHOLOGY
Bearing Addition Drill
Zone of Fluid Stem
ow
7. SCREEN
From (ft) To (ft) Code
Color Comment
Drill Rate
A(=>zq
-
Y Y /N i
F S
From (ft) To (ft) Type Slot Size Diameter
1
_
1'
/0
0
tJ 0
Y
Y Cl�,'
F S
ILI
0
Y �—N)
Y (N)
F S
Y N
Y N
F f S
8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL.
Y N
Y N
F S
From (ft) To (ft) Material Description Purpose
Y N
Y N
F S
00
Y N
Y N
F S
1111
El 11
Y N
Y N
S
Y N
Y N
F S
R Q
1 11 Ej
WELL
LOG
BEDROCK
Water
Bearing
Z one
Drop in
Drill
Stem
Extra
Large
Chips
Extra
Fast or
Slow
Drill Rate
Visible
Rust
Staining
Loss or
Addition
of Fluid
# Of
9. SITE SKETCH
LITHOLOGY
Fractures
per foot
From (ft)
To (ft)
Code
Comment
-7171
-t
i'rifir
61av
0
Y
Y /
F /
S
Y
Y
iv 6,
Y
Y /
F /
S
Y /,IT,
Y
A
Y
N
df�)
S
Y A('
N
6
Y
Y
F
S
Y iN
Y
fV0
Y /0
Y /(N
rF
S
Y IN,
Y
8 /q, 1\
Y
N
T)/
S
Y
(r 1
( I
) I
I '
I
4
fv
Y
IF
S
Y
5
f1t r
Y (14
F
S
Y N;
Y
41 `'-L3
SiS11
�",[ A
Y (f
"Y) / N
'I 'F)/
S
Y
Y /(4
I
k�'
Y (N
F / S
Y /(XIFT
Y/N10
10. WELL
TEST
DATA
(ALL SECTIONS MANDATORY
FOR PRODUCTION
WELLS)
11. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped
Pumping
Level
Time to
Recover
Recovery
Depth Below
Date
Method
(GPM) (hrs & min)
(Ft. BGS)
(hrs
& min)
(Ft, BGS)
Date Measured Ground Surface (ft)
Aj
0
0 (d
7
12. PERMANENT PUMP (IF AVAILABLE)
13. ADDITIONAL WELL INFORMATION
Pump Description
El El El El
Horsepower
Developed Y Fracture Enhancement Y
Pump Intake Depth
— (ft) Nominal Pump Capacity —
(gpm) Disinfected �Y)/ N Surface Seal Type El 0—
14. COMMENTS
e Total Well Depth Depth to Bedrock
15. WELL DRILLER'S STATEMENT applicable
JThis well was drilled, altered, and/or abandoned under my supervision, according to appF
rules
and regulations, and this
report is complete and correct to the best of my knowledge.
7 5 CP 5
6, I iv I
Driller:
Supervising
Driller Signature-
Registration #J
Wt" � A,
v,,!!"(
Firm:
Date Complete:
Rig Permit #:
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
05/04/2007 13:44 FAX
rO002/002
MANSFIELD BOARD OF HEALTH
APPLTCATION FOR PERMIT TOE WELL
Name
i .c: .n• •
Registered
Well Driller_ "LW IC - ONL-M GV,an.AMON IKC . MA Lie # KO M
Address: % 54rt,tao04 'O2t112, nt LGt &4 MA 02056
TYPE OF WELL:
'-"'Domestic Potable (for household use)
Domestic Awdliacy (for watering, pools, etc.)
Industriai/Commercial Potable (for human consumption, including food processing)
IndustnaVCommercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
Fee: NIA Domestic $10.00 _ Industrial/Commeerciaall�$11000.00 NIC Agricultural
Date: '5/0 2 107 Applicam Signature
The above application has been approved and permission is granted to drill a well for the
following use at
Domestic Potable (far 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)
Date; Approved by:
For the Board of Health
NOTE: Electrical perma required; underground cable trench must be inspected
Upon Installation of well, call Department of Pubbe Works office at
26.1-7330 to be added to well list
05/04/2007 13:43 FAX
[a 001/002
---- --
(Pennoni)
PENNONI ASSOCIATES INC.
CONSULTING ENGINEERS
100 Burtt Road, Suite 120
Andover, MA 01810
Tel: 978-749-9929
Fax: 978-749-9920
93 Stiles Road, Suite 201
Salem, NH 03079
Tel. 603-226-1950
Fax 603-226-3235
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