HomeMy WebLinkAboutHealth Permit # 3/4/2004 ,I
NUMBER
COMMONWEALTH OF MASSACHUSETTS BHP-M04-0309
North Andover FEE
$125.00
Board Of Health
George Henderson
-------- -------------------- - - ------------------------
NAME
Lot-3 FOREST STREET
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires---------------March-04,-2-006----------------unless sooner suspended or revoked.
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March 04,2004 Board Of
- ----------------------- i ------ Health
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BOARD OF HEALTH 2�7
�SSgCHU NORTH ANDOVER, MASS.
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,. AP1ICATION FOR WELL AND PUMP PERMIT
Permit # Date ._
A permit is requested toy drill a well install a pump
LOCATION: E,41,;, Lot
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owner�"Ir Cqo et Ej�J OGC 14 1 a Address �2 I-Aof) jr, ►M rI ,� Tel 17 -° 727- � �!
�U1 c .�-xc-)nS5
Well Ccntrctr o�i r�� � , Add. UZ q �p °c- Tel �.. 2
Pump Contrctr j ��' °- Add. Tel
WELLS (To be completed at time of pump test. )
Type of well i l-'a Use Vb m-e s "f`"C=
Diameter of well r Size of casing ��
Depth of bed rock ^� ` Depth casing into bedrock
Seal been tested? Yes ( ) No (�) Date of test ('y v `/
i _n.
Depth of well �, Water-bearing rock (y;-_A j yJ t- ,,
Depth to water / Z Delivers GPM for L.Ll /-/0,A? S .
p (how long?)
Drawdown (p feet after pumping hours at GPM
Date of completion Vj > Lv
Signatur of well contractor
PUMPS (To be filled in before installation. )
Name & size of pump 1." o�.;� v > � . ,Type
Size of tank � ' - `t Pump delivers ( 0 GPM
Pipe used in well: Cast iron (_) Galvanized (_) Plastic ( )
:sleeve used to protect pipe? Yes (�) No (` Type well sealse�2.. ,
_. ,..N
Date �(��. ,
Sig _ ure of pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector
Board of Health
Massach _ts Department of Environmental Manage: its
Office of Water Resources �.,o w
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TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE
Address at Well Location ' 1 - �� ' ' '�' Property Owner:
Subdivision Name Mailing Address: r
City/Town: �
y N own.
j ' -�-. ,;. {�,�'it.-� r�.� �-�. �"������
City/T
C1 !
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 j
2.WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD
Q New Well ❑ Abandon n Domestic ❑ Irrigation ❑ Cable ❑ Auger
❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ET Air Hammer ❑ Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rotary ❑ Other
S. WELL LOG OC Unconsolidated Consolidated 6. S3IT "SKETCH (Use"permanent landmarks with distances)
� Permeability T -0
c > m a
From (ft) To (ft) High Low m Other Rock Type .
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7.1 HELL CONSTROCTIQN
Total Depth Drilled �� ' From (ft) To (ft) Casing Type land Material Size O.D. (in) Well Seal Type
Date Drilling Complete c //%... (>
-.
9:
SCREEN ,
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10 0 LTE R PACK/-GROUT/A bANDONMENT MATERIAL 11.ADDITIONAL WELL INFORMATION
From (ft) To (ft) Material Description Purpose Developed? 'Yes El Fracture
Fracture i
Enhancement? Yes ❑ No
Method iYO E,
Disinfected? E] Yes ❑ No
12.
WELL TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (hrs& min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
14. PERMANENT PUMP(IF AVAILABLE) 15,NAMEIAODRESS OF PUMP INSTALLATION COMPANY
Pump Description / " >v
li } ' Horsepower ( ',
Pump Intake Depth " (ft) Nominal Pump Capacity � (gpm) ",o t�A
�
16.COMMENTS
17.E WELL!'DRILL R'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is complete-and correct tq the best of my knowledge.
Driller: " ( i � Supervising Driller Signature: Registration #: LI
> t f te: ,
� Ri Permit#: < t
NOTE: Well Completion Reports must be filed by the registered ivell driller within 30 days of well completion.
f T O ,'EL P
V/12/2004 17:14 97869200 " THORSTENSEN LAB PAGE 01
66 LITTLETON ROAD,WESTFORD, MA 01888 (978)652.8395 FAX(SM 692-0023 1.800.649-TEST
Rcport Number 80691 Report Date: 3/12/04
Client: Sample Information.:
Mike Finocebio Lot#3 Forest St.
68 Hood St, N.Andover,MA
Lynn MA 01905
Sampled by: Rollins Staff Date Received: 3/11/04 Date Sampled: 3/11/04
CertiScate ofAnalys
Test Parameter EPA Lmmit 1t alts lts
Total Cohfomt(P) 0 0 per100rn)
Fecal Coliform/E.eoli(P) Absent Absent perl00ml
Calcium Not Spec. 23.7
mg/L
Copper(S) 13 <0.02 m8/L
1zo4(S) 0.3 0,29 mg/L
Magnesium Not Spec. 5.9 mg/L
Manganese(S) 0105 0.05 mg/L
Potassium Not Spec. 1.0 mg/L
Sodium See Note 15.4 mg/L
Alkalinity(S) Not Spec. 94.0 rrg/L
Ammonia-N Not Spec, <0.03
mg/L Chloride(S) 250 5.9
mg/L
Chlorine Not Spec. 0.08 mg/L
Color(S) 15 7.5 CPU
Conductivity Not Spec. 229
L1m110d/cm
Hardness
Not Spec. 83 mg/L
Nitrate-N(P) 10 0.25 mg/L
Nitrite-N(P) 1 <0.01 mg/L
Odor 3 1 TON
PH(S) 6.5-8.5 7.5 SU
Suiphatc(S) 250 13.9 mg/L
Turbidity Not Spec, 2.6 NTU
Sediment poahleg neg
Legends:
(P)=Primary EPA Standard,(S)mSeoondwy EPA Standard,#==Exceeds EPA Limit,
TNTC=Too Nuoaerous to Count,*=Background Bacteria Noted,'=Exceeds Advisory Limit
Sodium Advisory Limits,lass.-20,NH-250.
This water supple as submitted,umets EPA guidelines for the parameters listed above.The
quality of this water is accepted as POTABLE according to EPA standards.
Massachusetts Certification#MA048 ichael P. C:ar on,for
Thorstensen Laboratory Inc.