HomeMy WebLinkAboutSouth Main St. #430 - 4/15/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name 'U(C - (Awt
l C/fR
Address q 3 D S�> malt)
-
Location 5 A /K r-
Registered /�
Well Driller C-- k-AV �.'-4J—A�"/ �jf1 CO " "l / ( 6?1 16 2C
Address
TYPE OF WELL:
_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.)
_Agricultural (for irrigation of land in the business of agriculture)
Fee: V-b-omestic $ 10.00 _Industrial/Commercial $ 1,000.00 N/C Agricultural
Date: ^J-S~- Applicant Signature:�Zjj Ar�
PERMIT TO DRILL A WELL
The above application as been approved and ermi i n is grant6d to drill a well for the
following use at 6 6( � (
Domestic Potable (for household use)
_
�-3Somestic 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 bps nets f agriculture)
/ Z "�� Approved b �._,_...
Date: � pp Y�
Foi'the Board of Health
i�Wi' t,t i,ar;
NOTE: Electrical permit required, underground cable g{rift µ�tibe'in3j��cted
Upon installation of well, call Department of Fublic Works office at
261-7331 to be added to well list "'' °'"
Massachusetts Department of Environmental Management
,
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1, WELL LOCATION
I GPS (OPTIONAL) LATITUDE'' LONGITUDE
Address at Well Location: Property Owner: „� A �
Subdivision Name Mailing Address
_
City/Town: y Cltyjovvn:
Assessors Map Assessors Lot #: 'NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes'10 Not Required ❑ Permit Number Date Issued
2, WORK PERFORMED
3. PROPOSED USE =
4. DRILLING METHOD
11 New Well ❑ Abandon
❑ Domestic M' Irrigation
❑ Cable El Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
O`Air Hammer: -❑ Direct Push
❑ Replace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rotary ❑ Other
5.. WELL LOG
Unconsolidated
Consolidated
6. SITE
SKETCH (use permanent landmarks with distances)
pone
a6ilily
a
a
m
m
From (ft)
To (ft)
High
Law
N
N
o
a
1
g
Other
Rock Type
r
l
r ,t
//0 `
i
fr
yr t
7. WELL CONSTRUCTION,
8.
CASING
Total Depth Drilled a ' l7
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
1 € 0
1 777
177771777f,',.,
Date Drilling Complete
B.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL '
11.iADDITIONAL WELL INFORMATION
Developed? ❑ Yes El - No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? EJ`Yes ❑ No
Method 1Z,
Disinfected? ED`Yes ❑ No
12. WELL TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL
(ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Depth Below
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Ground Surface (FT)
-
r
W
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description f ( Horsepower � ///.(
i �,', pl '
'Q i,C, 7
Pump Intake Depthyi)[7 (ft) Nominal Pump Capacity 2� (gpm)
16. COMMENTS
17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations; and this report-i"oroplete and correct to the best of my knowledge.
Driller:4ezb E=rz44d; Supervising Driller Signature:-"" Registration #:
Firm: l rl.,.'�� r ,�-..-, Date. (�,�'. Rig Permit#.'��
NOTE. Well Cetotpletion Reports most be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY