HomeMy WebLinkAboutBranch St. #234 - 6/6/2002Massachusetts Department of Environmental Management
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
13
1. WELL LOCATION
GPS (OPTIONAL) LATITUDE "LONGITUDE '
Address
l�/!'r/ t Well Loc� n:L)nq L? � 1-,`tsU i/ Proper Owner
Subdivfsi / .67Gh) 1olt Mailing Address: r� �a`_r�1Y)/D�11C�qtr�1 /fir TtV
City/Town: - / )s >l7('/
. /i� CiryTown: tnh,5l i � %l1Y�
Assessors Map Assessors Lot #: NOTE.Assessors Map and totV mandatory if no street address available
Board of Health permit obtained: Yes ❑ Not Required ❑ Permit Number Date Issued
2. VIIOFtlf PERFOR(u1ED,�' '."
3, PROPOSED USE ' ' `-s 4, bFULUNG METHOD
Cfl New Well ❑ Abandon
❑ Deepen ❑ Recondition
❑ Replace ❑ Other I
❑ Domestic ❑ Irrigation ❑ Cable Auger
❑ Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push
❑ Industrial ❑ Other 15PA(ge' ❑ Mud Rotary ❑ Other
5. WELL LOO,
`
CC
a
Permeability
Highj
Law
Unconsolidated
U)
m
co
g
other
Consolidated
Rock Type
-0 ITE SKETC}l (use permaperttlanamarks with distances)
-
�8:
fro vI �r�
m
/4/1 over c/rowe ,
From (ft) To (ft)
H a
tit
X
if
0 r
7. WELL CONSTRUCT
N
.CASING
Total Depth Drilled /� ,
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete
/
(j
L/ C
9.SCREEN
From (ft) To (ft) Slot Size" Screen Type and Material Screen Diameter
I /G r t ::r"., .f ,•�r
10, FILTER PACK / GROUT I ABANDONMENT MATERIAL
From (ft) To (ft) Material Description Purpose
11. ADDITIONAL WELL INFORMATION
Developed? El Yes El No
Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑ No
� t
/40
5441(f
I%7t
�eA=
12. WELL
TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Date Method (GPM) '`-(hrs & min) (Ft. BGS) (hrs & min) (R. BGS)
I
Date Measured
Depth Below
Ground Surface (FT)
14. PERMANENT PUMP (IF
AVAILABLE)
15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMEI..TS i j 1.tjz 11 /5-S 57 ,77
17, WELL DRIL4�R' CAT i NT' ` This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is complete and correct to the best of my knowledge.
' r'r -,
Driller: Supervising Driller Signature:_ Registration #J 1 ,��G= �L}
�ii
Firm: �C `t e (, � //U/([' �� Date: Rig Permit#: [ I
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
^::BOARD OF -HEALTH -COPY