HomeMy WebLinkAboutUnion St. #116 - 4/29/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
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Address:
Location:
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Telephone
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Registered
Well Driller:MA Lie #
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Address: C t(
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: / Domestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
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Date: Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at I I (P i-� i oV _ l-
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: ' 2 9 - cam`; Approved by: J ` U '%e k r.>
For the Board of Health
NOTE. Electrical permit required, underground cable trench must be inspected.
Upon Installation of well, call Department of Public Works office at
261- 733 0 to be added to well list
Massachusetts Department of Environmental Management 1246577
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE iiI LONGITUDE'
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Address at Well Location: ✓°ice C��J �•�- _" Property Owner:
Subdivision Name: Mailing Address: ✓
City/Town: 741 5' City/Town: In A,4�-
Assessors Map Assessors Lot #: NOTE: Assessors Map a I If m o f�% i1�0' et address available
Board of Health permit obtained: Yes Not Required ❑ Permit erf `D � ad
2. WORK PERFORMED 3. PROPOSED USE $ 4. DRILLIN TH
®''New Well ❑ Abandon ❑ Domestic 0 Irrigation Cable uger
❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ mer Direct Push
❑ Re lace ❑Other ❑Industrial ❑Other ❑Mud Ro Other
5. WELL LOG
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Unconsolidated
Consolidated
5. SITE SKETCH (use permanent landmarks with distances)
W
Permeability
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From (ft)
To (ft)
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Other
Rock Type
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7, WELL CONSTRUCTION"
8. CASING
Total Depth Drilled -' 5
From (ft) To (lt) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Comp to
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9. SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK I GROUT I ABANDONMENT MATERIAL
11.)ADDITIONAL WELL INFORMATION
Developed? M- es ❑ No
From (ft) To (ft) Material Description Purpose
Fracture
2. r; yeJ1-'.�"1i'O't'f%J C,�, S-d' rct� ``�7/t>
Enhancement? ❑ Yes ❑ No
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j �a"r"!``
Method
Disinfected? ❑ Yes ❑ No
12. WELL TEST DATA (PRODUCTION WELLS) i
13.iSTATIC 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 Mefasured
Ground Surface (FT)
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14. PERMANENT PUMP (IF AVAILABLE)
15, NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description 4 ITT,; f t777" l /-�f?� Horsepower
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Pump Intake Depth 5-I (#i) Nominal Pump Capacity 20 (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 re/port i complpt� qnd correct to the best of my knowledge
w Supervising Duller Signature: " .r as r.� ,_Registration `�
Driller ice® F� �.` ia�� �/
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Firm: i r� � ^ -- .t7,<%%,rr` Date ��- �'�'3'� Rig Permit #: Llr�.
NOTE: Well Completion Reports most be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY