HomeMy WebLinkAboutHealth Permit # 5/17/2010 COMMONWEALTH OF MASSACHUSETTS NUMBER
BHP-2010-0577
North Andover
FEE
Board of Health $135.00
---------------------------I-------HASE-L-TINE,-GEORGE
NAME
----------------------------------65-7-FOREST-STREET
ADDRESS
IS HEREBY GRANTED A PERMIT
We/II
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires --------------August-1 7,2010--------------unless sooner suspended or revoked.
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May 17, 2010 `�_ _ --_:------- Board of
-------- ------ ... ... Health
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Board of Health Chairman
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'FOWN OF NORTH ANDOVER
VE
Office of COMMUNITV DEVE1,0111M ENT ANA SERVICES
HEALTH LEPAT EN"
1600 OSGOOD ST4% # 'r; JI DING' 20 SLATE 236
NORTH ANDOVER, MASS C HL,1SEI`"S 01845
Susan '. Sawyer,l EI1S/RS 978.688.9540--Mona
Public Health Director 978M8.8476 16 --FA
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www.t<.>wiiottaot-tliaridover.coin
Well and/or Pump Application
(Please print) DATE: 4. k° � )lt�°y
LOCATION to Drill Well or install a pump: NCI 1'" l J1��a fit'>f�1 C
Licensed Well Contractor Name and Company Name: �SC�I �� C,l t��
Contact Phone Numbers:
p� t
Homeowner:
Address:
Contact Phone Numbers: tx w W�j r ' - r 1bV) " ter}y re li
WELLS(to be completed at time of pump test)
Type of well: tJse:
Diameter of well: Size of Casing:
Depth of bedrock: Depth of casing into bedrock:
Seal been tested? Yes( ) No( ) Date of test:
Depth of well: Water-bearing rock:
Depth of water: Delivers: GPM for:
(how long)
Drawdown: feet after pumping: hours at: GPM
Date of Completion:
Signature of Well Contractor
PUMPS(To be filled in before installation)
Name&size of Pump: Type:
Size of Tank; Pump delivers: GPM
Pipe used in well; Cast Iron_ Galvanized Plastic
Sleeve used to protect pipe? Yes No Type of well seal:
Date:
Signature of Pump Installer
Date water analysis report submitted to Health Department:
Plumbing Wiring Inspector Health Department Representative
C:\DOCUME-1\bcurran\LOCALS—I\Tetnp\Well Application.doc
Massachusetts Department of Conservation and ,Recreation
Office of Water ResOL11-CeS
'TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION I EGP:S:(R-:e�u red) North -7 777='
Address at Well Location: Property Owner/Client:
Subdivision Name: Mailing Address:
64-
City/Town: (9v, �,1
City/To
,12 o I wn: tl
Assessors Map—Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address a V able
Board of Flealth permit obtained: Yes s 114D Not Required ❑ Permit Number Date Issued
WORK PERFORMED 3. WELL TYPE 4. DRILLING II ETHOD 6, CASING
Overburden edrock from (ft) To (ft) Type --Tb`=ckness"--1Tia`meter
"P
LJ�11 ❑El I
U10D
01:10
54 WELL LOG OVERBURDEN — Water Loss or Drop In Extra
LITHOLOGY Bearing Addition Drill Fast or
Zone of Fluid Stem Slow 7. SCREEN
From (ft) To (ft) Code Color Comment VDrill Rate
From (ft) To (ft) Type Slot Size Diameter
Y N Y N F S
El El Ej
Y N Y N F S
Y N Y N F S 11 El El
0 1:1 Ej
Y N Y N F S
8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL.
Y N Y N -F S From (ft) To (ft) Material D—es—c'r-iptiori Purpose
Y N Y N F S 0❑ 0
Y N Y N F S
Y N
Y N
:Y N
Y / NN
v 1�1 El El El 1:1
HEALTH DEPARTMENT Y N Y N F S
❑ ❑
Y N Y N F S 1:1 El El 0
WELL LOG BEDROCK Extra 9. SITE SKETCH
-- Water Drop in Extra 'xt or Vi9ih'e Loss or of
LITHOLOGY Bearing Drill Large Fast Rust Addition Fractures
, Staining From (ft) To (ft) Zone Stem Chips "1 10 at aiing of Fluid per foot
Code Comment Drill Rate
�,j
--L1 L -LL Y N Y N F S Y N Y 1 N J
c, I Y N Y N F S Y N Y N
JY N Y N F S Y NJY N
Y N Y N F S Y N Y N
............
Y J N Y N F S Y N Y I N
Y N Y N F S Y N Y N
Y N Y N F S Y N Y N
Y N Y N F S Y N Y N
Y N Y N F S Y N Y N
N S Y NjILY N
JJY N L/ L
10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) T.—STATIC WATER LEVEL (ALL WELLS)
Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below
I Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (ft)
fAl
.......................
2. PERMANENT PUMP (IF AVAILABLE) 13, ADDITIONAL WELL INFORMATION
Pump Description El ED El 11 Horsepower leca Developed7, Y,/7
N Fracture Enhancement Y N
Pump Intake Depth f Vim. (ft) Nominal Pump Capacity EJ El L J
gy PP M 0) Disinfected(Y, N Surface S eal Type
14. COMMENTS Total Well Depth --LLL Depth to Bedrock
15. WELL DRILLER'S STATEMENT This well was drilled, altered, 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
Driller: Supervising Driller Signature: Registration #:
r
Firm: v" Date Cornplete: Ri Permit It:
IVOTE: Well Completimi Reports must be filed by the registRred well driller within 30 days of well completion.
BOAlFir"), OF HEAL."Ti-I COFlY