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HomeMy WebLinkAboutSouth Main St. #395 - 2/17/1998MANSFIELD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Name Location "k1_( IL Installer %Ely� A'd-eeelilo / ,✓ Address TYPE OF WELL: omestic Potable (for household use) �omestic Auxiliary (for watering, pools, etc.) _IndustriaUCommercial Potable (for human consumption, including food processing) _IndustriaUCommercial Auxiliary (for manufacturing, etc.) _Agricultural (for irrigation of land in the business of agriculture) Fee: _Domestic $ 10.00 _Industrial/Commercial $ 100.00 N/C Agricultural Date: a Applicant Signature: 12!: c/ k 61 PERMIT TO DRILL A WELL The above application has been following use at 13q �;_ is granted to drill a well for the Dpmestic Potable (for household use) omestic Auxiliwry (for watering, pools, etc.) _IndustriaUCommercial Potable (for human consumption, including food processing) _Industrial/Commercial Auxiliary (for manufacturing, etc.) _Agricultural (for irrigation of land in the busf agriculture) Date: a - l i — l `C oard otHealth NOTE: Electrical permit required, underground cable trench must be inspected, DepVment of Environmental Management/Division of Water Resources s WELL COMPLETION REPORT — TELL —LOCATION ©A'= Vvc" t i N S E W of Address �^ L (circle) (J�� city/Town m n e A (road) Well owner,y N S E W of r� Address l A YI (m,. in tenths) (circle) i} )Lv) r F i° I A M A of Healthpermitobtained: yes ntersect. w/—_------ ❑ no ❑ (road) Board WELL DATA WELL USE ❑ Public ❑ Industrial ❑ Total well depth '6---- ft. Domestic Other tar .Monitoring ❑ r Depth to bedrock material: Water -bearing rock/unconsolidated n ? Method drilled / / Description Date drilled Water -bearing zones: 1) From TO CASING AiP7"'--rLIV�u 2) FromTo Type � 3) From To /.i D(I D ) /!/Y in. Length is . dia. Length into bedrock ft. Gravel pack well: die. Protective well seal: Other �fr Grout Elpn h �' So Siot#_ IQ length_ ,�. from Ja to STATIC WATER LEVEL Date---" (all wells) Static water Ievei below land surface-9 ft. WELL TEST (production wells) ft. - after pumping hr.— min. at gPm Drawdown min. How measured Recovery ft, after_ hr. LOG of FORMATIONS COMMENTS o Materials From To Driller '. Firm (9- Pei Iligg Co Address own F /�P IV r supervising Ll Supervising Driller Reg.# � Please print firmly BOARD OF HEALTH COPY