HomeMy WebLinkAboutSchool St. #280 - 4/26/2004Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE' LONGITUDE
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Address at Well Location: u � r` D � �w--" � Property Owner: t'y Q
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Subdivision Name. Mailing Address 11
City/Town: E 0 ( 14 City/Town: 'A) i' ,'� `) L) /'1'( %t t ��� %} Qd 1 Cf
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes ❑ Not Required ❑ Permit Number Date Issued
2. WORK PERFORMED
3. PROPOSED USE
METHOD
C ew Well ❑ Abandon
❑ Domestic ❑ Irrigation
tILLING
able❑
Deepen ❑ Recondition
❑Monitoring ❑ Municipal
ir Hammer ❑ Direct Push
❑ Re lace ❑ Other
❑ Industrial ❑ Other
ud Rota ❑ Other
5. WELL LOG
W
Unconsolidated
Consolidated 16, SITE SKETCH (use permanent landlietrom with distances)
-
From (ft)
To (ft)
W
Q
Permeability
High
Low
..
co
, g
m
Other
'Y..'\R, A /
Rock Type f g ,_ �,
Oil
1
e
g(gt
7. WELL CONSTRUCTION
8.
CASING
Total Depth Drilled �D
From (ft) To (ft) Casing Type and Material Size O.D. (in) —Well Seal Type
Date Drill i g Com fete
Q
(/
9.SCREEN
From (ft) To( Slot Size Screen Type and Material Screen Diameter
l> t? 0/0 C1
10, FILTER PACK / GROUT ! ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? -1 Yes C'o"
From (ft) To (ft) r` Material Description Purpose
Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑ No
12. WELL TEST DATA (PRODUCTIONWELLS) 13, STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (bra & min) (Ft. BGS) (hrs & min) (Ft. BLS) Date Measured Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE) 115. NAME/ADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Oominal Pump Capacity (gpm)
16. COMMENTS v
97. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is mplet 'and eo`lrect to he best of my knowledge.
d)
)riller! t � / ty, /f �� d'� 1 0 Supervising Driller Signature' / 'lr Registration #. °')
loration Cor�f„ li,
oil Expp. Date: RioPermit #: � :j /t ,
1 nQ0rtJJf W , Reports must be filed by the registered well driller within 30 days of well completion.
Meominster, MA 01453 BOARD OF HEALTH COPY