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HomeMy WebLinkAboutSmith Rd. #47 - 3/24/200604/29/2003 TOE 09:19 FAX 509 201 T425 TOWN OF MANSFIELD W1002/003 P Name Addre; Looatii Registers Well ME Address: TYPE OF WELL: i =- MANSFIELD BOARD OF HEALTH ow n& APPLICATION FOR PERMIT To URIt,r, wrr.r. Pp P I. ne-,ed e et _ Domestic Potable (for household use) icz:fbomesfic Auxiliary (for watering, pools, etc.) IndustriaVCommereial Potable (for human consumption, including food processing) _ Industrial/Commcmial Auxiliary (for manufacturing, etc.) Agricultural (for imgation of land in the busincss of agriculture) Fee: �Domesti $10.00 _ industrial/C 'al $100.00 /C Agricultural Date: a-) J (C Applicant Si e• Cf �y„ PER1 M TO DRILL WELL The above application has been roved and permiss�oa is gamed to drill a well for the following use at _ Domestic Potable (for household use) omestic Auxiliary (for watering, pools, etc,) _Ind03WaVC0mnWcial Potable (for human consumption, including food processing) Industrial/Commercial Auxiliary (for romfacturing, etcJ Agicultuml (for irrigation of land in the business of agriculture) Date: J�-a�l ���y Approved by: Sc�p, le For the Board of Health NOXVr Eledrical permit required; underground cable trench must be inspected Upon Installation of wel4 call Department of public Works office at 26I-7330 to be added to well list; r:ER CONNECTION, INC. Water Well Resign & Project Management March 22, 2006 Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 RE: Application for Well Permit - 47 Smith Road Dear Sir/Madam: %6 Enclosed please find our Well Permit Application and required fee (if applicable) for the above referenced location. If our application meets with your approval, please fax a copy of the permit to my attention at 978-640-6901. Please do not hesitate to contact me you need additional information. Thank you for your assistance in this matter. cerely, / i N cy C pi Office Manat Enclosures 6 4 Rhoda Street ,,r Tewksbury, MA 01876 t,,� Phone (978) 640-6900 .h Fax (978) 640-6901 1, www.wellwaterconnection.com Massachusetts Department of Environmental Management Office of Water Resources -31 TYPE OR PRINT ONLY 1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE —"DATUM Address at Well Location: on: J Prop e: --7— —Afl"nr"ddress: Subdivision Nam City[rown: C Assessors Map Assessors dtj #: A A V NOTF-JAssessors Map and Lot # mandatory if no street address available 0 � Board of Heath permit obtained: Ye M' Not Required_ Permit Number — Date Issued 2. WORK PERFORMED Y43-PJROPOSED USE 4. DRILLING METHOD ED New Well ED Abandon I El Domestic-- ,, rigation EJ El Auger 10"Mud Ej, Deepen Recondition JEJ monitoring El municipal 'Cable ©'Air Hammer El Direct Push 'El EJ Replace 71 Other El Industrial El Other— Rotary E] Other 77 ELL LOG Water I Bearing Unconsolidated Consolidated 6. SITE SKETCH (use permanent tandrurkS With distances) I oth ier Rock Type and From (ft) To�i A 0 rn Material Description -1k"i l,t f 4f kg 7. WELL CONSTRUCTION 8. CASING I i Total Depth Drilled l From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Date Complete 67) 77777 9.SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? [A'Yes 0 No From (ft) To (ft) Material Description Purpose Fracture Enhancement? 123Yes EJ No Method / I I "if - 1, /-1-, 1 Disinfected? El Yes E--I No 12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Drawdown to Time to Recover Recovery to Depth Below Date Method (GPM) (hrs & min) (Ft, BGS) (firs & min) (Ft. BGS) Date Measured Ground Surface (FT) -o 14. PERMANENT PUMP (IF AVAILABLE) 16. NAMEADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth — (ft) Nominal Pump Capacity — (gpm) 16. COMMENTS I 17. 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. Supervising Driller Signature: Registration Driller� #: Firm: Date: Rig Permit NOTE: Well Completion Reports funist be filed by the registered well driller, within 30 days of well completion. 00ARD OF HEALTH C'OPY