HomeMy WebLinkAboutSouth Main St. #475 - 4/18/2001MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address LTelephone-
Registered Well Driller S 4 L ��U (Y) f RWD Number
V
TYPE OF WELL: U140mestic Auxiliary (for landscape watering) Fee: $ 10.00
I have read and understand the conditions listed in the permit below and agree to the
conditions.
1 1
Date: f Applicant Signature: i L
PERMIT TO DRILL A WELL
The above application has been approved�and�ermission is granted to drill a well
at: C s�1i11 1N��s�c— `-�� i
SUBJECT TO THE FOLLOWING CONDITIONS:
1. The resident or owner of the properk,, a:lees to use the well for irrigation
purposes only.
2. The resident or owner of the property agrees to allow Textron, Inc. (or their
agent) to sample the well prior to use and on a future periodic basis.
3. The resident or owner of the property will incur no cost for this sampling.
4. The resident or owner of the property must. provide to the Health
Department with information regarding construction 9fthe well in the form
of a Department of Environmental Management/Office of Water Resources
Well Completion Report.
5. The resident or owner of the property ag/rees t"otify the Board of Health
as soon as the well is in operation. / di
Date 2000 Approved by:
the Board of Health
✓'i I A I:J.J.;
Follow-up notes for after the well is drlleq;
1. Electrical permit required; underground cable ti' nch must be iuspicter-
1� , I'
2. Upon installation of well, call Department of Public c orks offac u(1�#1-7331 to be
added to well list.
3. Display "Well Water" sign.
,De,.artment of Environmental Management/Division of
WELL COMPLETION REPORT_,'
Address
CitviTown i4%l�i7i/ST�'5 i
rJ7777�k ^gyp U/tY/N4�
Well owner- r Address z '7-S_ 5oG17;'-1
Board of Health permit obtained: Yes X no ❑
Resources
//W N (S)E W of
(reef) (circle)
�w/k, �ia'U.-
/road)
N S E 9D of
(mi.. in tenths) (circle)
intersect.
)JELL USE
WELL DATA
Domestic ❑ Public ❑ Industrial ❑
Total well depth N ft
to bedrock
Monitoring ❑ Other //1/1 /�,atrC
Depth _��
_ -
Water -bearing rock/unconsolidated
Method drilled='
/material:
2O4/
Description
zones:
Date drilled
Water -bearing
2'2 2 s
CASING
.
f) From To
2) From To
Type
Length 11 it. Dia(I.D,) Z. in.
3) From To
-
Length into bedrock it.
Gravel pack well: dia.
Protective we
ProtectiveScreen:
dia.
?
%U from 2Zto g
Grout ❑ Other. /U,4YJ144
Slot# length ✓
STATIC WATER LEVEL (all wells)
_
Static water level below land surface
ft. Date
WELL TEST (production wells)
�'�I �� gpm
Drawdown / ft, after pumping
hr. ���min. at
How measured �p� Recovery - / ft.. after_ hr.�—min.
.LOG of FORMATIONS COMMENTS -
c�-
Materials From To
Driller
Firm
4P.
_ Address-
Supervising
BOARD OF HEALTH COPY