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HomeMy WebLinkAboutSouth Main St. #888 - 7/11/2007TYPE OR PRINT ONLY Massachusetts Department of Conservation and Recreation Office of Water Resources d,731/ I ' t rt Well Completion Report 1 WELL LOCATION GPS (Required) North-7 West Address at Well Location: p �/ p L Property Owner/Client: 0 Subdivision Name: o�o,/a %3. / /%o/n dfi?LJ Mailing Address: City/Town: tMO4S_Fi=alb City/Town: Assessors Map - Assessors Lot It: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required M Permit Number Date Issued' 2. WORK PERFORMED 3.,WELL TYPE 14. DRILLING METHOD 6. CASING 0❑�� Overburden Bedrock From (ft) To (ft) Type a Thickness Diameter --& ❑❑ El 5. WELL LOG OVERBURDEN Water Bearing Zone Loss or Addition of Fluid Y / N Drop in Drill Stem Y / N Extra Fast or Drill Slow Rate ri / at ❑ ❑ ❑ LITHOLOGY 7' SCREEN From (ft) +To (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment © ZS1 S— 4. Q,LQ vn Y/ N Y/ N F/ S ❑❑❑ . ❑❑❑ 1. --- Y/ N Y/ N F/ S g ANNULAR SEAL/FILTER PACK/ABANDONMENT MTLS Y / N Y / N F / S.'. From (ft) To (ft) Material Description Purpose .. Y/N Y/N F/S..; e` Y/ N Y/ N F /.S.;:. EL ' Y/N Y/NF/S.. ❑❑ Y/N Y/N F/S El 1 ❑❑ WELL LOG " BEDROCK Water Bearing Zone Drop in Drill Stem Extra Large Chips Extra Fast or `Visible Slow Drill Rate Rust Staining Loss or Addition of Fluid tt of Fractures per foot 9.SITE SKETCH LITHOLOGY From (ft) To (ft) Code Comment Y/N Y/N F/S Y/N Y/N Y/N Y../N F'/S Y/N Y/N T. Qb Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y I Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N Y I N Y/ N F/ S Y/ N Y/ Y/ N Y/ N F/ S Y/ N Y/ Y/ N Y/ N F/ S Y/ N Y/ flN Y/ N Y/ N F/ S Y/ N Y/ 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11' STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Date Method (GPM) (hrs & min) Pumping Level Time to Recover Recovery (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Depth Below Ground Surface (ft) 71 40164 12. PERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION Pump Description ❑ El ❑ ❑ Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Developed Y / N , racture Enhancement Y / NN n Disinfected Y / N Surface Seal Type ❑ 16U Total Well Depth � Depth to Bedrock 14. COMMENTS` Za 5/ 15. WELL DRILLERS STATEMENT '' This well was drilled, altered, and/or gbandoned under my supervision, according to applicable rules and regulations, and this eport£slomplFte a�ic� correct to the best of my knowledge. Driller:. - / r-�Q_. Supervising Driller Signature: q3, l��'d1IL) i��� Registration #:` ,fJt7 Firm: V8! ane Date-0om lete ¢ttaA�Rig Permit#: 1 1 L NOTE: Well Couipletimr Reports must be fled by the registered well dttlller within 30 days of well completion. F `iARD OF HEALTH COPY