HomeMy WebLinkAboutBranch St. #234 - 8/30/2001Massachusetts Department of Environmental Management Office of Water Resources 1 9 n 7
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION
GPS (,OPTIONAL) . LATITUDE LONGITUDE
Address at Well Location: ..5�6/�- Property Owner:
Subdivision Nam�� 4 �(a/lP 7 ��,�Y'fP Mailing Address: g- kchi7o%�L p /fl/7 ��YIyu- _
City/Town: Tfo s fie- au 1 / City/Town: _ CS bl-c /V/T 61a 4Z
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' j 1 DRILLING METHOD
❑ New Well ❑ Abandon
El Deepen El Recondition
El'Replace El Other
Cable Auger
Monitoring unieipal Air Hammer ElDirect Push
❑ Domestic ❑ Irrigation F-]
I --] Industrial❑ Other Mud Rotaa ❑ Other
S. WELL LOCH
'
¢
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Permeability
High
Low
�
"t
Unconsolidated
g
m
Other
Consolidated
Rock Type
S. SITE SKETCH (use permanent landmarks with distances)
From (ft) To (ft)
7. WELL CONSTRUCTION,
II -
CASING-
Total Depth Drilled a
From (tt) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date DII,n9 c pl
a t` C '
l ��
C✓ C -
9.SCREEN
From (it) To (ft) Slot Size Screen Type and Material Screen Diameter
141 6
/
CJ f ` ii .i n,.
10. FILTER PACK I GROUT / ABANDONMENT MATERIAL
From (ft) To (ft) Material Description Purpose
11. ADDITIONAL WELL INFORMATION
Developed? El Yes ❑ No
Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑ No
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32.. WELL
TEST DATA (PRODUCTION WELLS)
13. STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Date Method (GPM) "''' (Ins & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Depth Below
Date Measured Ground Surface (FT)
14, PERMANENT
PUMP (IF
AVAILA6LE) .
am
It. NAMEIADDRESS OF PUMP INST LLATION COMPANY
Pump Description Horsepower
Pump Intake Depth - (ft) Nominal Pump Capacity (gpm)
10, COMMENTS „
17. WSLL.DRILLER'S STATSNIET7T This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is c mplete and co rect to the best of my knowledge.
Driller: �Io// L d—,a(i Supervising Driller Signature: \Y `i�` � Registration #: 1 �; (° 6
Firm: vl&tS /', Date: Ri Permit #:
NOTE. Well Conrplelion Reports must be filed by the registered well driller within 30 days of well completion.
`BOARD OFHEALTH -.COPY.
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