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HomeMy WebLinkAboutWest St. #972 - 10/9/2007MANSFIELD BOAIW OF HEALTH TION VOR PFRMYF •ra Name Address: WELI, lte<F;istercul Wolf Driller: � �� ��/�(olj (� 1� 1���� _ _� � 1ViA Lis gelds: TYPE OF WELL: _ Domestic Potable (for household use) . Domestic Auxiliary (far waterlog, pools, etc.) lndtisteiaal/Coix me reial Potable (For human conssumPtion, including fo, d promssing) 1&fas&iu /(."onAnA=ial Auxiliary (for manufacturing, etc,..) M__.Agdoulttaral (for inigution of land in the, business of riewture) Fee: L� .e Domostio $10.00 _._.._ 1'ndustriwelon Date: j�© �/ Applicant SipuatUre: The; above appli following use at PERMrF TO D L rEl BL and permission is graaiteal to dial; ( a well for the Domestic, Potable (for household u ) ' r Domestic Auxilhuti' (for wAsl inn, }xsola, etc.) lndustriarllfrommewl�al Potable (forhuman comnlml tiora, 'rracludirag f, xacl lyracessing) _. lndustriaVeomuAercial Auxiliary (for manufacturing; etc.) _.e_ • Agn ul (far ° ipdou of land in ihr' asines_a of agriculture) Date: � ( � � Approved by: ~`W - _.._.._ w �iOr the P3cxard of ii h ArOTH. Flec trical p-,.rmit r°equir ed, aaerat'-ry round cable R'rent* > mvt be em, recur► N �y 1\ame --f Address: q'7 N Location: PV MAI SFIELD BOARD OF HEALTH AIPIPLIC.ATION Ia't)R PERAUT TO DI, LL WELL Telephone Registered , Well Driller. , = .i.. 11 _ __ MA Lie tgAKII�'. 5� Addmss: TYPE 017 WELL: Domestic Potable (foe household use) XDomestic Auxiliary (fox watering, pools, etc.) lndustrial/Cormne rcial Potable (tor human consumption, including RM d prooMingi Industrial/t ommoro aal Auxiliary (for Emufacturing, etc.) •Agriculuuart (for irrigation of rand in the busima s of agriculture) Fee: M. mestio $10.00 Date. Applicant Signature: __. PERAMP TO DRILL WELL The above applicta9i hrasbwn following use at _ �� is granted to dril I a well for the _ Domestic Potable (for household use) _ Damostic AuxifiwY (fear watering, pools, e^te:.) badmaial/Commerciai potable (for ha.tnaan consumption. including fad processing) iustxiaWora meeteial Auxiliary (foe: manufacturing, etc.) _777 xioaof land in tlr�rtrslxie s culture)ei Late:� Appiroved by: _ 1.� _ _ _ _ . or the Board of Hera) h M NOTE. Fk&r&al peraarrtt regsurse d, rarrdergnoum d cable trench muss! be MA re MA If pon Installafion of weA Call Depar nt vf'PubUC We rks ca ke at 261-7330 to be card to well &t. TYPE OR PRINT ONLY Massachusetts Department of Conservation and Recreation Office of Water Resources Well Completion Report d"'flu �5r 1. WELL LOCATION GPS (Required) North ') West °,, 3� g Address at Well Location.eb-2,roperty Owner/Clien/ P P d ati. Subdivision Name 't, 2 i €k ^ ar�fi a " / ` t` fvlailing Address: $ r a �� � r ° r/✓' ' ' rr City[Town: t/' F `'^- a"t.< City[Town: e' `ens ;.•F,z.�;T�•r°�i'`;^s-'.` 1 Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes M''.r-... Not Required O Permit Number Date Issued 2. WORK PERFORMED 3. WELL TYPE 14. DRILLING METHOD I' 6. CASING t - Overburden Bedrock. From (it) To (ft) Type ' Thickness Diameter ❑ ❑ ❑ 5. WELL LOG OVERBURDEN Water Bearing Zone Loss orFD Addition of FluidDrill Y / N Extra Fast or Slow Rate F / S ❑ ❑ ❑ LITHOLOGY 7' SCREEN s From (ft) To (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment ❑❑❑ --- Y/N F!S El 1:1 El --- Y/N ❑❑❑ 1. Y/ N Y/ N F f,S g ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL' Y / N -Y ! N ,P / S From[(ft) To (ft) Material Description Purpose R1 El Y / N Y l N F/ S <� ❑❑ ❑❑ Y/N Y/N F-S El El El El Y/N Y/N /S ;' ❑❑ ❑❑ WELL LOG BEDROCK Water Bearing Z Drop in Drill Ste m em Extra Large Chips Chi Exha Fast or Slow Drill p Drill gate Visible Rust Staining ,L-oss or Addition of Fluid a of Fracture per toot 9.>SITE SKETCH LITHOLOGY � t sr,fx t f fi �a From (ft) To (ft) Code Comment .1 Q:„ j Sr:>-"`f f%r`` Y/ N Y/ N F/ S Y /N Y/ N .Yj/ N Y/ N F/ S Y/ N Y/ N Y/ N Y /`N F/ S Y/ N Y/ N ,I Y/NY/N F/S Y/N Y/N Y/N'Y/N F/S Y/N Y/N Y/N Y/N F/S Y/N Y/N Y% N Y/ N F/ S Y/ N Y/ N Y/ N Y/ N F/ S Y/ N Y/ N - Y/NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11.iSTATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below Date, Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (ft) 12.lPERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION Pump Description '❑El ❑ ❑ Horsepower Developec�`Y�'/ N Fracture Enhancement YY/N) Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Disinfecte�°Y) / N Surface Seal Type n r Total Well Depth t p � Depth to Bedrock � 14. COMMENTS I 15. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision; according to applicable rules and regulations, and thrsre rt is comp) te'pnd correct to';Ihe best of my knowledge. z Driller � �'� �� % � �Supervising Driller Signature:-.? � `dr s/Ls'R) `w`4+"� Registration #J Firm: Date Complete. Alf f > � Riu Permit #. LL(L� (j NOTE.- Well Completion Reports must be filed by the registered wefll driller within 30 days of well completion. EaJARD OF HE61UM COP"! Massachusetts Department of Conservation and Recreation Office of Water Resources Ft ;_ e TYPE OR PRINT ONLY Well Completion Report 1.-WELLLOCATION GPS (Required) North -° �. West -. Address at Well Location' irs da.l r gN Property Owner/Client r ' >¢a �! ="gr°'°`� s fi. Subdivision Namear? eF't1-)t''�'Pr"�f �" a�r9Pt /:- a Mailing Address: �=`�t`�= L. �r'" " s f t d. City/Town: F a r¢!q d City/Town: Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot #mandatory if no street address available Board of Health permit obtained: Yes [Z➢ Not Required ❑ Permit Number Date Issued 2.`WORK PERFORMED ''r 3. WELL TYPE 4.'DRILLING METHOD 6. CASING y I''� �tr.. / p/ I Overburden Bedrock From (ft) To (ft) Type ' Thickness Diameter l"". 4' Pi.: ,e fi ``t YY Yt.." 3/ it &'], ✓f".y 1" 4.�,❑ ✓"p J. 1 000 5.WELL LOG'`' OVERBURDENi Water Bearing Zone Loss or Addition of Fluid Y N / Drop in Drill Stem Y / N Extra Fast or Slow Drill Rate F / g ❑. ❑ ❑ LITHOLOGY 7. SCREEN ' From (ft) To (ft) Type Slot Size Diameter From (ft) To (ft) Code Color Comment ❑❑❑ -� Y/N Y/N F/S ❑❑❑ _ Y/ N Y/ N F/ S ;❑ ❑❑ 1. Y/ N Y/ N F/ S 8 ANNULAR SEAL/FILTER PACKIABANDONMENT MTLs Y / N Y / N F / S '- From (ft) To (ft) Material Description Purpose Y/N Y/N F/SII..^;:,. ' 1,0 El Y/ N Y/ N F/ S ❑❑ ❑❑ Y/ N Y/ N F/ S ❑❑ 1 ❑❑ Y/N Y/N 'f/S ❑❑ ❑❑ WELL LOG BEDROCK Water Bearing Zone Drop in Drill Stem Extra Large Chips, Extra Fast or D 51 Rate " Visible Oust Staining Loss or Addition Fracture of Fluid N of per toot 9. SITE -SKETCH: LITHOLOGY ; `- I .w From (ft) To (ft) Code Comment :' 411o8 - V YlNY/N F,/S Y/N Y/N rF ',:, YINY/N F/S Y./N Y/N Y/NY/IN F/S Y/N Y/N Y 1>:N Y/ N F/ S Y/ N Y/ N f "o „i<, � Y/ N Y/ N F/ S Y/ N Y/ N 'ri<,t �.< 'a- � r i it : Y / N Y / N F / S Y / N Y / N �. Y'Y N Y/ N F/ S Y/ N Y/ N NY/N F/S Y/N Y/N Y/ N Y/ N F/ S Y/ N Y/ N Y/ N Y! N F/ S Y/ N Y/ N 10. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATICWATER: LEVEL (ALL WELLS) Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (ft) Y 12.PERMANENT PUMP (IF AVAILABLE) 13. ADDITIONAL WELL INFORMATION Pump Description ❑ ❑ ❑ ❑ Horsepower Developed( ,)/ N Fracture Enhancement Y / =N 7 Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Disinfected/�a/ N Surface Seal Type f Total Well Depth rift Depth to Bedrock' 14. COMMENTS 15. WELL DRILLER'S STATEMENT `: " This well was drilled, altered, and/or abandoned under my supervision, according to applicable rules and regulations, and this rgpofG is complete `and correct to the best of my knowledge. a t ,+ Driller )_' ` tr r('a 6 Supervising Driller Signature: t -/ '' ° Registration r Firm: c Date Complete: 447 '` 1 �y' ' Ri Permit # NOTE: Well Completion Reports must bf filed by the registered weld driller within 30 days of well completion. Cs r BOARD OF HEALTH COPY m N i fZ go