HomeMy WebLinkAboutTrowbridge Ln. #5 - 4/23/20035 1 11111"• 1
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address:
Location:
Registered
Well Driller:
Address:
TYPE OF WELL:
_ Domestic Potable (for household use)
A 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: ),S� Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: Applicant Signature: —
The above application has been approved and permission is granted to drill a well for the
following use at -5 Tr o �aE>f i o� Lo
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)
Date: `i a3 ((j 3 Approved by: J Zz-k-� �a \
For the Board of Pealth
NOTE. Electrical permit required; underground cable trench must be inspected.
Upon Installation of well, cull Department of Public Works office at
261- 733 0 to be added to well list
Massachusetts Department of Environmental Management 12 0 9 7 Z
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION I GPS (OPTIONAL) LATITUDES LONGITUDE
Address at Well Location: 1n1LProperty Owner: "j ���1 P�ALf LON)1=
Subdivision Name: Mailing Address: I o6 E 1,
City/Town: �3V I E I CitytTown: A N 1; t" I r I I 2-o
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes Fgj Not Required ❑ Permit Number Date Issued 1
2. WORK PERFORMED
3. PROPOSED USE 4.IDRILLING METHOD
Igh New Well ❑ Abandon
❑ Domestic Irrigation ❑ Cable ❑ Auger
O Deepen ❑ Recondition
❑ Monitoring ❑ Municipal Air Hammer ❑ Direct Push
❑ Replace ❑ Other
❑ Industrial ❑ Other ❑ Mud Rotary❑ Other
5. WELL LOG
[C
Unconsolidated
Consolidated
6. SITE SKETCH (Use permanent landmarks with distances) '.
W
N
Permeability
a
a
w
From (ft)
To (ft)
High
Low
in
m
to
'm
?
m
Other
Rock Type
RO(A)IPa,�I1)(a
(
7, WELL CONSTRUCTION t
6. CASING
Total Depth Drilled
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? ❑ Yes -No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes I No
Method
Disinfected? ❑ 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)
14, PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS Of PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, apcording to applicable rules
s, and rep complete and orr the gkst of knowled e.
A -
tin
Driller. f�l (t k _ Registration #:
�,( ( �-(-�l P SupervisinggDr Driller Signature:
si
Firm: " I (" i - - Date: ° -� Rig Permit #:
NOTE. ell Completion Reports must he filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY