HomeMy WebLinkAboutWest St. #390 - 3/10/200402/06/2004 FRI 12:00 FAX 508 261 7425 TOWN OF MANSFIELD
U 002/002
APPLICATION FOR PERMIT TO DRILL WELL
Name HoAC �>C RO-T`
Address: %JC'5 I- 5'f: tAM05F r L tj Telephone '177
2 Location. 1 6W n 17 4 tzat"Bce 2. fly 5,E W GAr'bCk) CF-ok)r Pe, Cnl'r&?A,0cE
Registered
Well Driller: ) L Mete P, CC (78J . 933 -32 t e�) MA Lic # 62
Address: 71 C10(Je&k1t> S7; 1JktTk—>C-AD1k)6 KA ei 04A
TYPE OF WELL:
Domestic Potable (for household use)
be-- Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agrtcailfiimi SfclF1l33gattRtl of n i rh hrsrin =ate �)— L--
Fee:
2 Domestic $10.00
_ Industrial/Connnercial $100.00
N/C Agricultural
bate:
. j/
Applicant 5ignatLAe:
PERMIT TO DRILL WELL,
The above application has be approved pd permission's granted to drill a well for the
following use ate
Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commereial Potable (for human consm ption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
Date: ��(� d 7 Approved by,/
Board of Health
NOTE. Electrical permit required; underground cable french must be inspected
Upon Installation of well, call Department of Public Works office at
261- 733 0 to be added to well list
03/10/04 WED 08:56 FAX 19766643299
D.L. MAHER CO. 16001
Wa[er
a divi:
erd
COMPANY
P.O. Box 127 . 71 Concord Street - North Pending, MA 01864
Tcl;781-933-3210 • Fox:978.664-3299
FAX Date: ' �� i0 2ta�
No. of Pages inI eluding cover:
I
To:
i
Phone:
From: 1'ED MOR.trX
D.L. Maher, a division of
Boarl Longyear Company
71 Concord Street
North .Reading, AIA 01864
Phone: 781-933-3210
Fax: 978-664-3299
Remarks: ❑ Urgent erFor your review O Reply ASAP 0 Please comment
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Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDELONGITUDE
Address at Well Location: ) ' ' a " "` Property Owner: r t ,tvt %' t` tr. C'
Subdivision Name: p (tTM jfit +''ej '—� Mailing Address: t<� Yv )X
City/Town: !A/AAk,, V t G City/Town:
Assessors Map i ( Assessors Lot #: ° NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes K, Not Required ❑ Permit Number OoAe, Date Issued ' ft",' iM
2. WORK PERFORMED
3. PROPOSED USE
14. DRILLING METHbD
Q New Well ❑ Abandon
❑ Domestic ij Irrigation
❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal
Rj Air Hammer ❑ Direct Push
❑ Re lace ❑ Other
❑ Industrial ❑ Other
❑ Mud Rotwy ❑ Other
S. WELL LOG
Unconsolidated
Consolidated
6. SITE
SKETCH (use permanent landmarks with distance.)?,
W
Permeability
—
h
From (ft)
To (ft)
High
Low
=
N
N
(5
0
g
m
Other
Rock Type
M,JK
I
Ifil.k
1'7
ED
�7,t
zf
7. WELL CONSTRUCTION':
6.
CASING
Total Depth Drilled Vd
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Dril ing Complete
)
On-E ww,I ,
11. "j w'
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? El Yes ®No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes d No
Method
Disinfected? ❑ Yes ❑ No
`
12. WELL
TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS) '
Yield Time'Pumped Drawdown to Time Recoveryto
Depth Below
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Ground Surface (FT)
E "hI a r R
A ( L',
I (
14. PERMANENT PUMP (IF AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description ir)6''a;,�6. ;CT _ p Horsepower f�iar�
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
17. WELL DRILLER'S STATEMENT ' This well was drilled and/or abandoned under rye '60ision, according to applicable rules
and regulations, and this report i� complete a fJ q rreLt to the best of my knowledge.
Driller: t WtA ta3 Supervising Driller SignaturRegistration #:
Firm:, L � � 40, r c 'g',, ` ' ' t" v : Date: " 9� Ri Permit #:I 12 155
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
.rc,�" 4l.�f � Gl a".3 Lie'✓ F--�+?f�
TYPE OR PRINT ONLY
Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE LONGITUDE
Address at Well Location: ;'a J a °j ) + ° Property Owner: `- L( e%,tcro L 1_ r %
Subdivision Name: o--9>dii, '-'t-("�� Mailing Address: I j'
City/Town: p i 1 1 €t City/Town: $'fit&YS!Vei� 1 f' f 1d f 1G g
Assessors Map ( Assessors Lot #: _-' NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes IA Not Required ❑ Permit Number sP ni Date Issued
2. WORK PERFORMED
3. PROPOSED USE 14. DRILLING METHOD
FA New Well ❑ Abandon
ILI
❑ Domestic Q Irrigation ❑ Cable ❑ Auger
❑ Deepen ❑ Recondition
❑ Monitoring ❑ Municipal ® Air Hammer , ❑ Direct Push
❑ Replace ❑ Other
Industrial ❑ Other ❑ Mud Rota ❑ Other
6, WELL LOG +
cr
Unconsolidated
Consolidated
6. SITE SKETCH (Use permanent landmarks with distances)
`
W
Permeability
m
6
From (ft)
To (ft)
High
Low
O
N
in
ca
m
Other
Rock Type
7
i � (iLiilY 't T;
7-. WELL CONSTRUCTION +
8. CASING
Total Depth Drilled 1
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete fJ t . d._, ,.
"o v kvlc
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? M Yes El No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? ❑ Yes 0 No
Methodat'
Disinfected? [ Yes ❑ No
LLL—
12. WELL TEST: DATA (PRODUCTION WELLS)
13.`STATIC WATER LEVEL
(ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Depth Below
Method (GPM) (hrs & min) (Ft. BGS) (Firs & min) (Ft.9BGS)
Date
Ground Surface (FT)
'Date
r/ � :"�
K't,%g^'4 t�
«J� IO F'" 4�,J f'n,(
k t� • C1�.a
P.. i�4` e-,%
"��l, � �
/Measured
f� J� /�.��'�
�) �q ��
14. PERMANENT PUMP (IF AVAILABLE) 15. NAME/ADDRESS OF PUMP INSTALLATION COMPANY i.
Pump Description 000E ` aw 6 Horsepower
Pump Intake Depth (it) Nominal Pump Capacity (gpm)
16. COMMENTS'
17, WELL DRILLER'S STATEMENT This well was drilled and/or apandoneo, undf r 7i (iq ision, according to applicable rules
(sQo)nple/tile
and regulations, and this rep q a, d c �c�to the best of my knowledge.-,
r
Driller: VO P'/IL'L'1f1 Supervising Driller Signature: ' Registration #:i I6rl I i
I
5Firm: a" 1. I^�al 1.,€'U :�. cAE�l ;,� K�'.s".� P.._ �(..-;r'(k-. Date: "� � �'I RigPermit #: ��ILJ
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
13OPRD° OF HEALTH COPY