HomeMy WebLinkAboutWilliams St. #111 - 2/28/2006Massachusetts Department of Environmental Management 9� i)� -7
Office of Water Resources �Jy
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE 0 LONGITUDE —0 "DATUM
Address at Well Location: U-.]) L,i r JV t Property Owner/Client:
Subdivision Name: Mailing Address: 2V) I' al Lt %f rra 1 j-) r 1 '14
CityfFown: — CityTrown: �!) llt") A
Assessors Map — Assessors Lot NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes UT Not Required El Permit Number — Date Issued
2. WORK PERFORMED
3. PROPOSED USE
4. DRILLING METHOD
O'New Well El Abandon
173 Domestic El Irrigation
EJ Cable EJ Auger
ILI-Mud
El Deepen 0 Recondition
El Monitoring El Municipal
171 Air Hammer El Direct Push
EJ Replace El Other
E-1 Industrial 0 Other—
Rotary EJ Other
5. WELL LOG
Water
Bearing
Unconsolidated
Consolidated
6. SITE SKETCH (use permanent landmarks with distances)
>i%
Other Rock Type
and
From (ft) To (ft)
Zones
E5
Material Description
`,j VjL, I
1 1,19
7. WELL CONSTRUCTION
8. CASING
Total Depth Drilled
From (ft)
TO (it) Casing Type and Material Size I.D. (in) Well Sea[ Type
Date Complete
1- jy-1171�
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK / GROUT ABANDONMENT MATERIAL
-111. ADDITIONAL WELL INFORMATION
Developed? El Yes 0 'No
From (ft) To (ft) Material Description Purpose
Fracture
Enhancement? E3 Yes El No
Method V t,t_ra J1 i-
Disinfected? D, Yes L1 No
12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
13. STATIC WATER LEVEL(ALL WELLS)
Yield Time Pumped Drawdown to Time to Recover Recovery to
Depth Below
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured Ground Surface (FT)
-'lld
si.
14. PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
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17. WELL DRILLER'S STATEMENT This well was drilled, alfered,, and/or abandonpdunder my supervision, 7—cordilng to applicable
rules and regulations, and.this report is complete and correct to the best of my knowledge,
Driller: Llt)'�zj L71) Supervising Driller Signature: Registration #:I
Firm: Date: "e, R12 Permit ft: t 10 k" I
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
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BOARD OF HFALTH COPY