HomeMy WebLinkAboutSouth Main St. #309 - 3/31/2011Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Application for Permit to Drill Welly"
NAME OF OWNER:REGISTERED7A(fWELL DRILLER:
ADDRESS OF OWNER: �,N Olt. ' 4; MA LIC #: 736
Town of Mansfield
BUSINESS ;P®. Rom'
TOWN / STATE / ZIP: P,4tJXF,e4:b f'%A `1 g/� ADDRESS: ✓kA-lek'v'
TELEPHONE No: ®�+�.2,9
v b
-bR;A4itj6�)
,/ , -
TYPE OF WELL: Domstic Potable (for household use)
Domstic Auxiliary (for watering, pools, etc.)
Ej Industrial/Commercial Potable (for human consumption, including food processing )
Industrial/Commercial Auxiliary (for manufacturing, etc.)
Ej Agricultural (for irrigation of land in the business of agriculture)
FEE: (X Domestic $10.00 ❑ Industrial/Commercial $100.0 ❑ N/C Agricultural
DATE C1_ y j, ell APPLICANT SIGNATURE' `�
Permit to Drill Well
p
The above application has been approved and permission is granted to drill a well for the following use
Domstic Potable (for household use)
[J Domstic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
r] Industrial/Commercial Auxiliary (for manufacturing, etc.)
0 Agricultu,al (for it igation of land in the business of agriculture).-%
DATE: _ �(/ VIt APPROVED BY
-----
he Board of Health
NOTE Electrical permit re urred, underground cable trench must be inspected �,� � �����g,pty: -'
nodegred sinceYrere ire uszdsrc�ron 4nb1etSc stlbJpQrsibl�e
P�lii,, �,.:amf�mpxoyan�",fin „e�cs��ng . a3�csue- rouxr.. P ��,. s sta' �i�` and
�J�ion rttst�llat►onot' well, cal`I Dea�r�m��� o�'u��►o ls�or�s o Vice at
261-7330 to be added to well list,
i;.mounts oz..a":oQi<ctete pad located in the basement of my carriage barn'.
FILE # K 1095
CENSUS TRACT N 6102
CLIENT: Attorney Rymond C. Lantz, Jr
DEED BOOK 1388 PAGE 105
PAGE LOT
OWNER: Richard G &Marion D Horton
APPLICANT: Norman C & Jac reline A. Corliss
PLAN BOOK
ASSESSORS PLAN PLOT
MORTGAGE INSPECTION
PLAN of LAND
I N
M A N S F
I E L D
JULY 22, 1992
SCALE: 1°= 100'
LOT 104 48s. 4AssESSoRs
%.41.(A)
L.OT 84
�339
2,9 AC
.
133.30(A�/
132,7'(p)
LOT 102
509.0 (A)
LOT 83
0
STAKES �r'?ci4rrJG
S7'AhD1)r)
anw�
® W
Q
LOT 8Z e��eo dog
it
4. '
So, MAIN SrRLF-T
I CERTIFY TO ATTORNEY RAYMOND C. LANTZ, JR., PRINCIPAL MUTUAL LIFE INSURANCE
EASEMENTS EXCEPT
COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMENTS .OR
AS SHOWN AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION.
THE LOCATION OF THE DWELLING AS SHOWN
HEREON IS IN COMPLIANCE WITH THE LOCAL
APPLICABLE ZONING BY-LAWS WITH RESPECTTO
art
HORIZONTAL DIMENSIONAL REQUIREMENTS.
Massachusetts Department of Environmental Protection
Bureau.of Resource Protection
WELL DRILLER
Please specify work performed:
[New Well
Please specify well type_:
�Irrigatlon
Number Of Wells:
Well Location
In public _dg_ht-of way:
C Yes C W l,
SubdlvlslonlProperly/Description:
Property Owner:
NORMANCORLISS
Engineering Finn:
Address at well location:
Street Number
Street Name:
F309_-
ISOUTH MAIN STREET
Building Lot#:
Assessor's Map #:
Assessor's Lot#:
ZIP Code:
f _...
02048.
CllyRown:
MANSFIELD
GPS
North: West:
— —
42.00835 71.12848
Malting Address:
r click here g same as wal I location address
Street Number:
Street Name:
�309 _.,..
(SOUTH MAIN STREtZ...-
City/Town:
State:
MMISFIEID
MASSACHUSETTS
ZIP Code:
02048
Board of health permit obtained:
r Yes C Not Requlred.�
Perm!( Number:
Date Issued:
10._.-.
r3/31/2011 _.-
Page t of 1
ML3vachusetts Department of Environmental Protection
Bureau of Resource Protection —Well Driller Program
Well Completion Repoffs(Goneral)
Well Driller- General Well Form
DRILLING METHOD
Overburden Bedrock
(Mud Rotary 1 fAlr Hammer
WELL LOG OVERBURDEN LITHOLOGY
From To(ft) Code
(ft)
III Sllty, Sand And Gravel
3` (Clay
I31 ! I51 1 (Clay —.
151 II 171 1 LlaY
71 I9 (Clay -
WELL LOG BEDROCK LITHOLOGY
From To(R) Code
(ft)
�91 I191 I IBhale
1191 ,.� I2io i Shale
235 ! 240 [Shale
f 240 260 -1 (Grants
ADDITIONAL WELL INFORMATION
Developed r Yes re Noi
Total Well Depth 1266 -- -
Drop In
Extra fast or slow
Loos or addition of
Color
Comment
drill stem
drill rate
(Bwn
ro
Yes
I l: Fast.
r Slow_
(fluid
I-.r Loss
r Atldltlon-�,
i0alai ck_ _-
ryes
Fast
�° Slow
Loss
r Addition(
(Black_
I r Yesi
` r Fast
r Slow
-�
L r Loss
r Addition i
---- (� Yes
r Loss
r Addition
I r Fast G Slow
I r Yesll
I r Fast
to Slow
(-r Loss
r Additions
Visible
Extra
Comment Drop in
Extra feet or Blow
Lose or addition of
Rust
Large
drill stem drilirate
fluid
Staining
Chips
r Yes
F^ Fast
r Siow
r Loss r Addition
(� Yesl
I_r Yes
rrYes
r Fast
G Slowl
r Loss r Addition
I r Yesl
f- Yes
I r Yes
r Fast
r Slowl
C Loss r Addition
r YesI
I- Yes
r- Yes r Fast 0 Slow r Loss r Addition I r Yes I F Yes
Disinfected
Depth to Bedrock
r Yes r No
Fracture —
Surface Seal Type INorre _ _ Enhancement r ('yes to W
CASING (✓ Is Casing above -ground?- From: 2. O
To: -
From To Type Thickness Diameter Drlveshoe
�
0 —. 160 .. IIrsteel 17# 6 r� Yes
I-�_.
SCREEN IF No Screen
From To Type Slot Size Diameter
Type -
WATER4BEARING ZONES II F DRY WELLI
From To Yield (gpm)
Page t of
MaegaohusoHa Department of Environmental Protection
Bureau of Resource Protection — Well Driller Program
Well Completion Reports(Geherall
1235 1240 _ 1 119
PERMANENT PUMP OF AVAILABLE)
--- Choose Pump --- Choose Horsepower --
Pump Description Description--- Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm) _
ANNULAR SEAL I FILTER PACK
From To Materiel t
Weight Material
Weight Water(gal)
Batches Method Of Placement
_-iI Choose Material-
f (Choose Matedel�—I
Choose
WELL TEST DATA
Time
Pumping
Time To
Recovery (ft
Date Method
Yield (gpm) Pumped
Level (it
Recover BGS)
(HH:MM)
BOB)
(HH:MM)
14/25f2o I1 Air With Drill Stem
f
I18 _ j 0:10
no
0:30 [40
WATER LEVEL
Date Measured Static Depth BGS (it) Flowing Rate (gpm)
_--_ __ ------ -----
14t2512011 �tc �1a
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this report Is complete a
knowledge.
Driller REINAIDOSiLVEIRA Registration # [MO Monitoring [M) �.._ _I Supervising Drill
Firm ACEDRILLINR MC. Rig Permll # 10227 _ _ _ Date Job Compl
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
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