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Miscellaneous - 657 FOREST STREET 4/30/2018
657 FOREST STREET 210/105.D-0029-0000.0 c O ---------- L G� North Andover Board of Assessors Public Access Page 1 of 1 a i= NORTH North Andover Board of Assessors Ot,t��o y1NO sAC64U t� roperty Record Card Click Seal To Return Parcel fD:210/105.D-0021-0000.0 FY:2010 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge rg ac i Search for Parcels i Search for Sales ' Summary Residence Detached Structure Condo 657 FOREST STREET Commercial Location: 657 FOREST STREET Owner Name: RABS,KENNETH M DOROTHY A RABS Owner Address: 657 FOREST STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6-6 Land Area: 2.20 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3583 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 408,400 440,100 Building Value: 192,400 222,300 Land Value: 216,000 217,800 Market Land Value: 216,000 Chapter Land Value: LATESTSALE Sale Price: 0 Sale Date: 12/31/1976 Arms Length Sale Code: N-NO-OTHER Grantor: Cert Doc: Book: 01300 Page: 0756 http://csc-ma.us/PROPAPP/display.do?linkId=1518496&town=NandoverPubAcc 7/14/2010 ' NORT►1 '616 0 q�0 O - ey FILE COPY ' [OCNK CwKN V ��sSgcHus���y PUBLIC HEALTH DEPARTMENT Community Development Division RTI FIC. 4rrc OF C0-MP. 1AirVff As of: - August 30, 2010 This is to cert that the individuaCsu6surface disposal system received a SAVSFAC ORTIMTECII05V of the: &ffSeptic System Instalration Foran On Site SewageDisposaCSystem By: Wiliam Taotw Sauyer At: 657 Forest Street 911ap-105.B; Parcel— 210 9Vo* rth Andover,, X9 01845 the Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. e• he�e E. Grant Fu6fc9fealth Inspector 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Regarding Septic Installation:Lot:21,657 Forest St North Andover MA To Whom it May Concern: I,George Haseltine,owner of 657 Forest ST North Andover MA absolve the town of North Andover,MA and the installer,Tom Sawyer of Arco Escavation,of any and all liability due the absence of finish loam and seeding of the yard,specifically referring to the yard over the septic system. This note is indented to provide relief of liability in order to have the Board of Health municipality approve the finish grade over the septic system without the finish loam and seeding being completed. If you have any q io s or need anything further please feel free to email me or call me. George Haseltine 603.85.8768 cell George.Haseltine@gmail.com NORT#q TO'" of. Andover O ..... No _ 7//Ae- LAK -O dower, Mass., COCMICMEWICK 7d�0RATED BOARD OF HEALTH en PERMIT TSe tic Syste h Cj sC S"p ® GQ r '� B LDIN NSPEC R THIS CERTIFIES THAT at.'.................................................. ...... ..................... ce. datio Jr . has permission to erect........................................ buildings on ... �r�—. .... .......,......................................................... Ro { �C f� Tt �!j Chimney to be occupied as.........................................�.....x.......��.h.. ..... ............ .......................................................... provided that the person accepting this permit shall in every respect conform toterms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. CFinal " PERMIT EXPIRES .IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Doug p :r v _ervice BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No. Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No.' SEE REVERSE SIDE Smoke Det � � 3 11, Commonwealth of Massachusetts IVCity/Town of NORTH ANDOVER Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health.Other fortes may be used,but the information must be substantially the same as that provided here.Before using this form.chedr with the local Board of Health to determine the forth they use. This is to Ce0v that the followinc work on an Onsite Sewaae Dlsoosal Svstem knporfanC whao Yang Out ® Construction of a new system tame On the 0 Repair or replacement Of an existing system fir.1se ❑ Repair or replant of an existing system component a*the tab key WWI cursor--do not Has been done in accordance with Title 5 and the Disposal System Construabn Permit(DSCP): use the nature kev. Dip Number DSCP Date r Facary Owner 657 FOREST STREET Sliest Aft—or Lot• NORTH ANDOVER AAA 04845 CAVrown state no cods Designer Information: BENJAMIN C.OSGOOD.JR. NONE e Nam of Comma w 8-26-10 Ign Date tncfAiler Intrver+aM+r+• Role Name of Company DOW Use of this systern Is conditioned on compliance with the provisions set forth below. The issuance of this certificate shall not be construed as a guarantee that the system wib function as designed. AtNxe+�B /'-7 G Af _._�. t0kena.doa oeraa cWtIficm of cmroYsno•Papa i Of 1 TOWN OF NORTH ANDOVER Office of CONINIGNITY DEVELOPNIENT,kND SERVICES a• '' HEALTH DEPARTMENT � /,/,,',P'WOSGOOD STREET NORTH,%`DOVER,MASSACHUSETTS 01845 f Susan Y.Sawyer,REHSIRS 975.688.9540—Phone 978.688.8476—FAX Public Health Director E-MAIL:healthdept•atownofnorthmtdover com WEBSITE:hap' www tounofnoRhandovrrcom TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM-INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System OQ constructed;( )repaired; by (Print N ) located at 49? Fygtcl Q- jJ. A NDa€1Z (Installation Address) was installed in conformance with the North Andover Board of Health approved plan,originally dated 4glej, Z3 pA d last Revised on .S- 67 D ,with a design flow of L/8 „ gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date Z 6 1 a Engineer Representative(Signature) And-Print Name Final Inspection date: Engineer Representative(Signature) And-Print Name Install (Signature) Date:V?j—1-0 And-Print Name Eng4mr. (Signature) Date: And-Print Name ` NORTF4 Os t.,LEO I,q-rO e OL O A LAKI ��SSACNUS���� PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 657 Forest Street MAP: 105D LOT: 21 INSTALLER: Tom Sawyer DESIGNER: Ben Osgood, Jr. PLAN DATE: 3/20/10 BOH APPROVAL DATE ON PLAN: 5/20/10 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: () 1 10 DATE OF FINAL CONSTRUCTION INSPECTI N: 8/26/10 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS NA Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan IV Bottom of tank hole has 6" stone base Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTF4 Q �t"o 0616 0 2 t,, ey O LANI ,k [OCNICNIM,KN y �.q 404�rEo P't SSACHUS� PUBLIC HEALTH DEPARTMENT fommunity Development Division Visual testing ® Inlet tee installed, centered under access port ® Outlet tee installed, centered under access port (effluent filter) ® 24" inch cover to final grade installed over outlet access port ® Hydraulic cement around inlet & outlet Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box NA Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution NA Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan NA Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 t pORTty Os tg1.110 16 3? �' - ... " 6 OL `O ~ to r 6 O140 COCK C lMCM 1' Art 9SSACHUS�� PUBLIC HEALTH DEPARTMENT (ommunity Development Division SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ® Number of chambers per row: 8 ® Number of rows (trenches): 5 Comments: Total Chambers = 40 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.iownofnorthandover.com Inspection Form June 2008 14ORT 4 Q ttLEO 16 q{/O 6 OL O to y� ,L T T � n ey � O LAKI 1 c"..c MI...v 4°gATeo �SSACHUS�� PUBLIC HEALTH DEPARTMENT (ommunity Development Division BM = 98.48 HR = 5.26 H 1 = 103.74 SYSTEM ELEVATIONS ROD ELEVATION AS-BLT INVERT ELEV DESIGN INVERT ELEV Benchmark 5.26 98.48 Building Sewer OUT 100.98 Septic Tank IN 3.86 99.53 99.38 Septic Tank OUT 4.17 99.22 99.13 Distribution Box IN 4.50 98.89 98.93 Distribution Box OUT 4.68 98.71 98.76 Lateral 1-5 TOP 4.76 Lateral 1-5 INVERT 98.63 98.66 Top of Chamber 4.76 98.98 99.00 Bottom of Bed/Chamber 5.76 97.98 98.00 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 VAORTty Q��""a 86 q�rO 0 0 16 � Co' � Q LAKI (OCMI[MIWK•y1 40R4TE0 �SSACHUS�� PUBLIC HEALTH DEPARTMENT Community Development Division 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com Inspection Form lune 2008 66 NORT14 % 6 OL O 6 A-O COCMIC MIWKII V1 7a g6RATED rPP��y IISSACHUSE PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck,on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains(wat. supply/trib.) 50 100 ® Drains(intercept g.w.) 25 50 ® Drains(Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws r 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, August 26, 2010 11:35 AM To: Grant, Michele Subject: FW: 657 Forest Street-Septic As Built and Certification Attachments: image002.gif FYI. Susan has the paperwork. I will prepare a COC for Monday for you. From: Sawyer, Susan Sent: Thursday,August 26, 2010 11:11 AM To: DelleChiaie, Pamela Subject: RE: 657 Forest Street- Septic As Built and Certification Ok Remember if the owners want to submit a letter stating they absolve the installer of the obligation to loam and seed, they can have an inspection of the final grade without those items. From: DelleChiaie, Pamela Sent:Thursday, August 26, 2010 11:04 AM To: Sawyer, Susan Subject: 657 Forest Street- Septic As Built and Certification Hi Susan, George from Forest Realty Trust came by and dropped off the As Built for 657 Forest Street. He has the state issued COC form with Ben's signature. I gave him our local form. He asked if the signature on the other form could be used and attached to our form, as Ben is difficult to meet up with due to his schedule. He also wanted to schedule a Final Grade which Michele can do on Monday....so, if you have time today,the As Built and form need to be reviewed and approved before I can issue the COC for him. 9W RC9414, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover,MA o1845 ph: 978-688-9540 fax: 978-688-8476 " "— r us ocusin on thepebbles under ourfeet."--Anonymous We can never see thepath o our life i we are too b P f .f f Yf g P I Y 1 �j S�4 3 � 1 i Vv'� ,ORTH Commonwealth of Massachusetts Map-Block-Lot 105.D0021 Board of Health Permit No BHP-2010-0704 ,n North Andover ----------------------- �° ' P.i. FEE . . :....... ��s-•,��.,¢��F F.I. $250.00 SACWU$ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted William T.-Sawyer--------------------------------------------------------------------------------- to(Construct-NEW SYSTEM)an Individual Sewage Disposal System. at No 657 FOREST STREET -----------------------------------------------------------------------------------------------------------=---------------------------------------------- as shown on the application for Disposal Works Construction Permit No. -BHP-2010-070- - - --- Dated --August 13,2010 ------ ----- -- ---- ----- ----------- "' Issued On:Aug-13-2010 o�f,�°ealth y .r f Application for Septic Disposal System --//-/� 3?•� TODAY'S DATE =Construction Permit — TOWN OF ORTH ANDOVER MA 01845 $250.00—Full Repair ....• $125.00-Component ss,C„„SE Important: Application is hereby made fora permit to. When filling out Construct a new on-site sewage disposal system* forms on the computer,use gRepair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information_ C � >�ISTS 7, � Address or Lot# City/town ©r/C 2.-*TYPE OF SEPTIC SYSTEM*: ❑ PumpGravity(choose one) ***If pump system,attach copy of electrical permit to application*** ❑Conventional System(pipe and stone system) Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information Name lei Address(i different from above) Cityrrown State Zip Code Telephone Number 3. Installer Informatio _ NamV � Name of Company Address Cityfrown State Zip Code 47 36 0 -7r3 Z Tele hone Num r(Cell Phone#if possible please) 4. Desi ner Inform ion Tzt*CJAO r 1 a/__I /4 It Named Name of Company _K 064 Address t✓uwN �e L� c�_ a /!2 q D City/rown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 r N°RTp Application for Septic Disposal System ?Gi�i...e` •y00 Construction Permit - TOWN OF TODAY'S DATE ORTH ANDOVER, MA 01845 $250.00—Full Repair � "°•,_••�"°'� $125.00-Component SSS CMU`+t4 PAGE 2OF2 r A. Facility Information continued.... 5. Type of Building: JAResidential Dwelling or❑Commercial , B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and n t to place the system in operation until a Certificate of Compliance has been issued by this B and of Health. Name Date Applicata Ap ved By: (Board of Health Representative) - 1 Z,— 7p/cation Date DisaM roved for the following reasons: For Office Use Only: L Fee Attached. Yes No 2. ProJectManager Obligation Form Attached? Yes ✓ No 3. Pump Ssv tem? If so,Attach copv ofElectrical Permit Yes �✓�No 4. Foundation As'Bur'lt?(hew construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 J SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by I`— C['l r� a �,Q_�U'1 / c (Engineer) Relative to the application of / f" (Installer's name) And dated //l�/�C A ngm ate Dated g r(�� ID �Io ay s ate With revisions dated 41—� I —1 (Last revised date) for management of this project: =its and Board of Health approved plans prior to z ( � he aptirr oved plans and the permit on site when any work is / pections. If homeowner,contractor,project manager,or any y schedules an inspection and the system is not ready,then cessary work completed prior to the applicable inspections as g an inspection,without completion of the items in accordance [ ions may result in a$50.00 fine being levied against me and or he first(1s) inspection unless there is a retaining wall,which -7 — Z'3lust request the inspection but does not have to be present. ?ngineer must first do their inspection for elevations,ties,etc. healthdeptnn townofnorthandover.com) from the engineer must i,after which installer calls for an inspection time. Installer must a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work(other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: d �� / (Today's Date) TN2ne— rint ame— t e J SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ST- _D (Address of septic system) For plans by �/C4 r� G �--,of Q (Engineer) Relative to the application of 4j I,/)/ S(Installer's name) And dated lCi` g o/0" (Original ate Dated r(l— /D kioilays ate With revisions dated Z_ (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the ap2roved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting inspection,without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or MY coM12anY. a. Bottom of Bed—Generally,this is the first(15) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built of verbal OK(or e-mail to:healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work(other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I fin-ther understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover,significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pomp chamber, retaining vall and other components. 6. As the installer,I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or another ther persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) TNIZe—Print) ame— i e n a WJa17�i:S{•'iLo SYSTEMS INC This is to certify that: William Sawyer Arca Ercavalors hassatisfactorily completed the required training program for the installation of the INFILTRATOR®leaching chamber system for on-site wastewater disposal applications.This person is certified to install the INFILTRATOR® chamber system as set forth by the Massachusetts DEP approval letter for INFILTRATOR drainfield chambers. All other guidelines as set forth by the latest revision of 310 CRM 15.00 of Title 5 will apply.This certificate was sealed and issued 12/31/2007. Certification:MA2187 Lee Verbridge Atlantic Regional Manager r DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, August 16, 2010 10:41 AM To: Grant, Michele Cc: DelleChiaie, Pamel Subject: FW: 114127-Hase in -657 Forest St-N An r MA.pdf Attachments: 114127-Haseltine-6 MA.PDF;well regs adopted 3.02 altered 6.24.04.doc Pam, Michele took a phone call from George Haseltine this AM. If George has additional questions please refer him back to these emails. He was going to do a second water test before OC per my request. -----Original Message----- From: George Haseltine [mailto:george.haseltine@gmail.com] Sent: Wednesday, June 02, 2010 11:53 AM To: Sawyer, Susan Subject: Re: 114127-Haseltine-657 Forest St-N Andover MA.pdf Hi Susan, No problem about the second test, we will perform prior to CO. Thanks for the reply. My Project Manager, Joseph Saltalamacchia,will be coming in with the paperwork to get the permit signed tomorrow. Will you be around then as well? George On Wed, Jun 2, 2010 at 10:53 AM, Sawyer, Susan<ssa , er(?townofnorthandover.com>wrote: >Yes, I am able to sign the building permit. Are you coming in today? > I have to go out at 12:15— 1, but should be around otherwise. >The well is potable. However the parameters that exceed the limits >will affect the quality of the water;there may be odor, off tastes >and will result in laundry staining issues. > I am requesting that a second test be conducted prior to occupancy. > This is for a couple of reasons. > 1) The fluoride reading is unusually high for a drilled well. > This is confusing. i > 2) I think a confirming test should be completed before > determining what/if any type of filtration system should be >considered. There are a couple of items that should be addressed if >they are confirmed and Health may require them. > 3) Since this system is on septic, please note that the septic >tank will not be approved to accept the back wash from any filtration > system. A separate dry well should be sited. > Thank you > Susan >From: George Haseltine [mailto:george.haseltine@gmail.com] > Sent: Wednesday, June 02, 2010 9:52 AM >To: Sawyer, Susan > Subject: Fwd: 114127-Haseltine-657 Forest St-N Andover MA.pdf >Hi Susan, >Please see attached water results from well. Can I proceed with sign >off with condition of filtration sytem for elevated iron if required? > George > George Haseltine > 603.785.8768 cell >Begin forwarded message: >From: "Mike Pelletier" <mpelletier@skillingsandsons.com> >Date: June 2, 2010 9:27:15 AM EDT •To. George Haseltine george.haseltine@gmail.com > Subject: FW: 114127-Haseltine-657 Forest St-N Andover MA.pdf >Here you go George,just hit my email. >Mike Pelletier > Skillings & Sons Inc. 2 > > 9 Columbia Drive >Amherst NH 03031 > Celebrating 40 years of quality service ! > Office: 603-889-5009 > Cell: 978-697-1294 > Fax: 603-821-3822 >From: David Knowlton [mailto:Dave@NashobaAnalytical.com] > Sent: Wednesday, June 02, 2010 9:26 AM >To: Carl LaChance; Derek Skillings; Kerry Roy; Mark Suprenant; Mike >Pelletier; Scott Wilkins > Subject: 114127-Haseltine-657 Forest St-N Andover MA.pdf George Haseltine George.Haseltinekgmail.com 603.785.8768 cell 3 Nashoba Analytical, LLC Tel:978-3914428 Fax:978-3914643 LabNumber: 114127 31A Willow Road,Ayer MA 01432 Website:http://www.NashobaAnalytical.com Use this number with all correspondence Client: Skillings and Sons, Inc. ReportDate: 6/2/2010 9 Columbia Drive Amherst, NH 03031 Certificate of Analysis 21390 Parameter Method Result MCL MRL Date of Analysis Analyst -George Haseltine, 657 Forest Street, North Andover MA Sampled:5/28/2010 2:15:00 PM by J. Gove Total Coliform Bacteria,/100ML MF-SM9222B 0 0/Absent 0 5/28/2010 4:00:00 PM M-MAI118 Arsenic,Total,MG/L SM 3113B ND 0.01 0.002 5/29/2010 M-MAI118 Calcium,MG/L EPA 200.7 6.3 Not Spec 1 6/1/2010 M-MA1118 Copper,MG/L EPA 200.7 ND 1.3 0.01 6/1/2010 M-MA1118 Iron,MG/L EPA 200.7 # 1.46 0.3 0.01 6/1/2010 M-MA1118 Lead,MG/L SM 3113B ND 0.015 0.002 5/28/2010 M-MA1118 Magnesium,MG/L EPA 200.7 1.6 Not Spec 1 6/1/2010 M-MA1118 Manganese,MG/L EPA 200.7 0.029 0.05 0.005 6/1/2010 M-MA1118 Potassium,MG/L EPA 200.7 ND Not Spec 1 6/1/2010 M-MA1118 Sodium,MG/L EPA 200.7 61.2 See Note 1 6/1/2010 M-MA1118 Alkalinity,MG/L SM 2320B 116 Not Spec 1 6/1/2010 M-MA1118 Ammonia,MG/L SM 4500-NH3-D ND Not Spec 0.1 6/1/2010 M-MAI118 Chloride,MG/L EPA 300.0 5.8 250 1 5/28/2010 M-MA1118 Chlorine,Free Residual,MG/L SM 4500-CL-G ND Not Spec 0.02 5/28/2010 M-MA1118 Color Apparent,CU SM 2120B # 25 15 1 5/28/2010 M-MA1118 Conductivity,UMHOS/CM SM 2510B 358 Not Spec 1 5/28/2010 M-MA1118 Fluoride,MG/L EPA 300.0 3.4 4 0.1 5/28/2010 M-MA1118 Hardness,Total,MG/L SM 2340B 23 Not Spec 2 6/1/2010 M-MA1118 Nitrate as N,MG/L EPA 300.0 0.05 10 0.05 5/28/2010 M-MA1118 Nitrite as N,MG/L EPA 300.0 ND 1 0.01 5/28/2010 M-MAI118 Odor,TON SM 2150B 1 3 0 5/28/2010 M-MA1118 pH, PH AT 25C SM 4500-H-B # 8.6 6.5-8.5 5/28/2010 M-MA1118 Sediment,pos/neg ---------- neg ----- neg 5/28/2010 M-MA1118 Sulfate,MG/L EPA 300.0 22.2 250 1 5/28/2010 M-MA1118 Total Dissolved Solids,MG/L SM 2540C 228 500 1 6/1/2010 M-MAI118 Turbidity,NTU EPA 180.1 11.4 Not Spec 0.1 5/28/2010 M-MA1118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), *=Background Bacteria Noted Massachusetts Certified David L.Knowlton Page 1 of 1 Laboratory#MA1118 Laboratory Director TOWN OF NORTH ANDOVER BOARD OF HEALTH WELL REGULATIONS The Board of Health of the town of North Andover, Massachusetts acting under Chapter 111, Section 31 of the Massachusetts General Laws, as amended and with reference to Chapter 40, Section 54 of said General Laws has, in the interest of and for the protection of public health and the environment, established and adopted the following rules and regulations : Section 1. DEFINITIONS 1. 1 The word "well" as used in these regulations shall include any pit, pipe, excavation, casing, drill hole or other private source of water to be used for the purpose of supplying potable water , in the town of North Andover. This includes irrigation wells. 1.2 The words "water systems" as used in these regulations shall include pipes, valves, fittings, tanks, pumps, motors, switches, controls and appurtenances installed or used for the purpose of storage, filtration, treatment or purification of water for any use whether or not located inside of a building. 1.3 The words "well contractor" as used in these regulations, shall mean any person, association, partnership, company or corporation that installs, constructs or repairs a water system associated with a well. 1.4 The words "non-essential well" as used in these regulations refers to all wells that are not the sole source of potable drinking water for a site, whether residential or commercial . Section 2 . PERMITS 2 . 1 No well shall be constructed until a well permit has been issued by the Board of Health. Such a permit shall be applied for by a well contractor registered with the town of North Andover. A fee will be charged as found in the current North Andover Board of Health fee schedule. 2 .3 Appropriate wiring and plumbing permits shall be applied for and issued by the Building Department prior to well construction. 2 .4 No building permit shall be issued for the construction of a building which necessitates the use of water therein for a well located on the land where the building is to be constructed, until a well has been installed and the Board of Health has determined that a safe and adequate supply of potable water is available. 2 .5 A well form shall be issued along with the well permit to be filled out by the well and pump contractor. Such a form must be filled out accurately and copies kept on file at the Board of Health upon its completion. Forms received which are not representative may be cause for the revocation of the contractor' s registration. 2 . 6 Major renovation or repair of existing wells and/or water systems must be approved by the Board of Health. 2 . 7 A permit for the construction of a well shall not be issued for any property located within the Lake Cochichewick Watershed that currently has reasonable access to the town water system. The watershed boundaries are as found within section 4 . 136 of the North Andover Zoning Regulations, "Watershed Protection District" . 2 . 8 The Board of Health may deny an application for a non- essential well when it is in the interest of public health to do so, as in times of drought. Section 3 . WELL SITING 3 . 1 The location of a well must be within the boundaries of the lot in which it will be in service. 3 .2 There shall be a separate well for each building. It shall be constructed up-gradient from all sources of potential contamination and must be located at distances which are to be equal to or in excess of the following; 1) 100 feet from any septic leach field or existing underground storage tanks 2) 75 feet from any septic tank 3) 50 feet laterally from the normal high mark of any water source 4) a minimum setback of 25 feet from all streets, lot lines and driving surfaces. 5) 20 feet from existing building sewers, and underground swimming pools 3 .4 The well shall not be placed within a defined wetland or in an area of consistent flooding. Any proposed well located within 100' of a wetland is subject to regulation by the Wetlands Protection Act. The BOH shall receive a copy of written approval from the North Andover Conservation Commission prior to the issuance of a well permit in these cases. Section 4 . CONSTRUCTION REQUIREMENTS 4 . 1 The well contractor shall observe reasonable sanitary measures and precautions in the performance of his work in order to prevent the pollution of contamination of the well. 4 .2 Newly constructed wells or wells where repair work has been done shall be thoroughly disinfected before being put into use. 4 .3 Every well shall supply adequate water for the purpose for which it is intended and shall give satisfactory evidence of continuing capability to do so. 4 .4 Before being approved, every well shall be pump tested by the well contractor (4 hr pump test) . The results of the pump test shall be submitted on the well form issued by the Board of Health. A well shall exceed the following flow rates, or it shall be considered inadequate for a single family dwelling. Well Depth Gallons per Minute for Four Hours 0 - 150 5 - 6 150 - 200 4 200 - 250 2 - 3 250 - 300 1 -2 350 and over 1/2 4 .5 There shall be a single and separate water system for each dwelling and it shall not be installed or materially altered until the Board of Health is notified. The Board will require a description of the installation or repair to be conducted. Emergency work for repairs or service of existing equipment not amounting to a substantial renovation or overhaul may be done without notification. Appropriate inspections by wiring or plumbing inspectors will be required before final Board of Health approval. 4 . 6 All pumps, motors and tanks shall be placed on a suitable foundation and all equipment and parts of the system that may require adjustments or service shall be made readily accessible. 4 . 7 All pump houses, pump or pipe pits and wells shall be designed and constructed so as to prevent flooding and otherwise to prevent the entrance of pollutants or contaminants. 4 . 8 The Board of Health shall require the installation of all necessary switches, controls and devices, and the satisfactory performance of a pressure and operating test of the system before final approval; the test must demonstrate that the system will deliver adequate pressure and volume consistent with the well and the well requirements. The Board of Health must be given reasonable notice of when the installation is ready for inspection. 4 . 9 No certificate of occupancy shall be issued until all the provisions of these regulations have been met. The inspections and these regulations cannot be construed as a guarantee by the town of North Andover or its agents that the water system will function satisfactorily. Section 5 . WATER QUALITY 5 .,1 In cases of new construction, the Board of Health shall require the submission of a water analysis report. The report shall include bacterial and chemical evaluations conducted by a laboratory approved by the Board of Health or the Massachusetts Department of Public Health. Laboratories conducting testing must supply a copy of Massachusetts certification as verification that it holds current certification for all types of analysis done on water samples. The submission of a chemical analysis to the Board of Health is required before issuance of a building permit. The bacterial analysis must be conducted after the water system is completely installed. A report must be submitted before the Board of Health will issue final approval. The following minimal parameters must be included in the water analysis. total coliform alkalinity arsenic calcium chloride * indicates Primary Contaminants color copper hardness iron lead magnesium manganese nitrogen (ammonia) * nitrogen (nitrite) * odor pH * potassium sediment sodium sulfate turbidity total dissolved solids - i Additional information shall be required if the well is in an area of agricultural use or within 500-1000 feet of utility rights-of- way 5 .2 All primary contaminants shall meet EPA standards. Based on the results of the water analysis reports, the Board of Health may require additional treatment of a water supply. Section 6 . PERMANENT OR TEMPORARY WELL ABANDONMENT 6 . 1 All permanently abandoned wells shall be tightly sealed by approved methods to prevent pollution of the ground water. Prior to plugging, the well shall be checked for debris that may interfere with the process. If the integrity of the original well seal is in doubt, the casing shall be removed or perforated. In addition all pumping equipment and associated plumbing shall be disconnected and removed. 6 .2 When a well is not abandoned, but is out of use for an extended period of time, it shall be the owner' s responsibility to properly maintain the well and to prevent the development of defects which may facilitate the impairment of water quality in the well or in the water bearing formations penetrated by the well. Until a well is permanently abandoned by plugging procedures, all provisions for protection of the water from contamination and for maintaining sanitary conditions around the well shall be carried out to the same extent as though the well were in routine use. 6 . 3 To temporarily abandon a well, the top of the well casing shall be sealed with a watertight threaded cap or with a steel plate welded watertight to the top of the casing. If the top of well seal is watertight, the pump may be left in place. A well that has, after extended use, been temporarily abandoned for three (3) years shall be considered permanently abandoned, and shall be appropriately plugged. Section 7 . PENALTIES 7 . 1 Any person who shall violate any provisions of these regulations for which a penalty is not otherwise provided in any of the General Laws or Sanitary Code shall upon conviction be fined not less than fifty nor more than five hundred dollars. Section 8 : UNCONSTITUTIONALITY CLAUSE 8 . 1 So far as the Board of Health may provide each section of these rules and regulations shall be construed as separate to A the end that if any section, item, sentence clause or phrase shall be held invalid for any reason, the remainder of these rules and regulations shall continue in effect. Gayton Osgood, Chairman Dr. Francis P. MacMillan Dr. John Rizza, Clerk Published N.A. Citizen, February 9, 1984 Rev. 9/90 Rev. 8/93 Rev. 1/02 r 1 pORTH O161 tiO PY(/�! O CfK NKMtWKN y1' �.9 A�q�TEO pPP��y SSAC HUSH PUBLIC HEALTH DEPARTMENT (ommunity Development Division May 20, 2010 Forest Realty Trust 32R Old Point Road Newbury,MA 01951 RE: Subsurface Sewage Disposal System Plan for 657 Forest Street,North Andover, Massachusetts Assessor's map 105D, Lot 21 Dear Property Owner, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property. These plans dated March 20, 2010, final revision date of May 15, 2010,have been approved for a four(4)bedroom,maximum nine-room home. In accordance with local subsurface disposal regulations"Acceptable plans and any variances shall expire two years from the date approved unless construction on the lot has begun". During this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer and the Town of North Andover. This approval is subject to the following conditions: 1. Prior to receiving a building permit, the applicant must provide complete floor plans of the new home. Please include all living spaces. 2. Prior to receiving a Disposal Works Construction permit,the applicant must provide a foundation plan in 1"=20' scale to overlay on the septic plan. 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com I Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Since ell' , 7 i Susan Sa er, REHSrR �'''L-- . Public Health Director Cc: Richard Tangard, P.E. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com HUU-1b-d010 11:00 From: To:16036428952 P.1/1 Pitchervflle Sand 8 Gravel 36 Brown Drive Greenville, NH 03048 603-878-0035 CUStOmer Arco Excavators (fax) 603-878-0025 Job: 557 Forest St. N.Andover Sieve Analysis Tit_,,, le b She tic Source Hubbardston Date 8/11/2010 SIEVE SCREEN CUMLATIVE CUMLATIVE TOTAL% An W L WGL %REIAINED MSING 318" 0 0.00 0.00 100.0 #4 11.51 4.26 95.7 #8 24.60 9.09 90.9 #16 63.74 23.56 76.4 #30 92.80 34.31 65.7 #50 178.90 66.14 #100 33.9 240.10 88.76 11.2 #200 260.90 96.45 3.55 PAN 270.50 100.00 0.0 Nashoba Analytical, LLC Tel:978-391-4428 Fax:978-391-4643 LabNumber: 114127 31A Willow Road,Ayer MA 01432 Website:http://www.NashobaAnalytical.com Use this number with all correspondence Client: Skillings and Sons, Inc. ReportDate: 6/2/2010 9 Columbia Drive Amherst, NH 03031 Certificate of Analysis 21390 Parameter Method Result MCL MRL Date of Analysis Analyst -George Haseltine,657 Forest Street, North Andover MA Sampled:5/28/2010 2:15:00 PM by J. Gove Total Coliform Bacteria,/100ML MF-SM9222B 0 O/Absent 0 5/28/2010 4:00:00 PM M-MA1118 Arsenic,Total,MG/L SM 3113B ND 0.01 0.002 5/29/2010 M-MA1118 Calcium,MG/L EPA 200.7 6.3 Not Spec 1 6/1/2010 M-MA1118 Copper,MG/L EPA 200.7 ND 1.3 0.01 6/1/2010 M-MA1118 Iron,MG/L EPA 200.7 # 1.46 0.3 0.01 6/1/2010 M-MA1118 Lead,MG/L SM 3113B ND 0.015 0.002 5/28/2010 M-MA1118 Magnesium,MG/L EPA 200.7 1.6 Not Spec 1 6/1/2010 M-MA1118 Manganese,MG/L EPA 200.7 0.029 0.05 0.005 6/1/2010 M-MA1118 Potassium,MG/L EPA 200.7 ND Not Spec 1 6/1/2010 M-MA1118 Sodium,MG/L EPA 200.7 61.2 See Note 1 6/1/2010 M-MA1118 Alkalinity,MG/L SM 2320B 116 Not Spec 1 6/1/2010 M-MAI118 Ammonia,MG/L SM 4500-NH3-D ND Not Spec 0.1 6/1/2010 M-MA1118 Chloride,MG/L EPA 300.0 5.8 250 1 5/28/2010 M-MA1118 Chlorine,Free Residual,MG/L SM 4500-CL-G ND Not Spec 0.02 5/28/2010 M-MAI118 Color Apparent,CU SM 2120B # 25 15 1 5/28/2010 M-MA1118 Conductivity,UMHOS/CM SM 2510B 358 Not Spec 1 5/28/2010 M-MAI118 Fluoride,MG/L EPA 300.0 3.4 4 0.1 5/28/2010 M-MA1118 Hardness,Total,MG/L SM 2340B 23 Not Spec 2 6/1/2010 M-MA1118 Nitrate as N,MG/L EPA 300.0 0.05 10 0.05 5/28/2010 M-MA1118 Nitrite as N,MG/L EPA 300.0 ND 1 0.01 5/28/2010 M-MA1118 Odor,TON SM 2150B 1 3 0 5/28/2010 M-MA1118 pH,PH AT 25C SM 4500-H-B # 8.6 6.5-8.5 5/28/2010 M-MA1118 Sediment,pos/neg ------- neg ------ neg 5/28/2010 M-MA1118 Sulfate,MG/L EPA 300.0 22.2 250 1 5/28/2010 M-MA1118 Total Dissolved Solids,MG/L SM 2540C 228 500 1 6/1/2010 M-MA1118 Turbidity,NTLI EPA 180.1 11.4 Not Spec 0.1 5/28/2010 M-MA1118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), '=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director Page 1 of 1 Sawyer, Susan From: Sawyer, Susan Sent: Wednesday, June 02, 2010 10:54 AM To: 'George Haseltine' Subject: RE: 114127-Haseltine-657 Forest St-N Andover MA.pdf Yes, I am able to sign the building permit.Are you coming in today? I have to go out at 12:15—1, but should be around otherwise. The well is potable. However the parameters that exceed the limits will affect the quality of the water; there may be odor, off tastes and will result in laundry staining issues. I am requesting that a second test be conducted prior to occupancy.This is for a couple of reasons. 1) The fluoride reading is unusually high for a drilled well.This is confusing. 2) 1 think a confirming test should be completed before determining what/if any type of filtration system should be considered. There are a couple of items that should be addressed if they are confirmed and Health may require them. 3) Since this system is on septic, please note that the septic tank will not be approved to accept the back wash from any filtration system. A separate dry well should be sited. Thank you Susan From: George Haseltine [mailto:george.haseltine@gmail.com] Sent: Wednesday, June 02, 2010 9:52 AM To: Sawyer, Susan Subject: Fwd: 114127-Haseltine-657 Forest St-N Andover MA.pdf Hi Susan, Please see attached water results from well. Can I proceed with sign off with condition of filtration sytem for elevated iron if required? George George Haseltine 603.785.8768 cell Begin forwarded message: From: "Mike Pelletier" <mpelletier@skillingsandsons.com> Date: June 2, 2010 9:27:15 AM EDT To: "George Haseltine" <g_eorge.haseltine(@),gmail.com> Subject: FW: 114127-Haseltine-657 Forest St-N Andover MA.pdf Here you go George,just hit my email. Mike Pelletier Skillings & Sons Inc. 9 Columbia Drive Amherst NH 03031 Celebrating 40 years of quality service ! i Office: 603-889-5009 Cell: 978-697-1294 Fax: 603-821-3822 From: David Knowlton [mailto:Dave@NashobaAnalytical.com] Sent: Wednesday,June 02, 2010 9:26 AM To: Carl LaChance; Derek Skillings; Kerry Roy; Mark Suprenant; Mike Pelletier; Scott Wilkins Subject: 114127-Haseltine-657 Forest St-N Andover MA.pdf 2 Benjamin C. Osgood, Jr., P.E. � ��� 7 PO Box 71 Amesbury,MA 01913 ►p� Tel: 508-3284633 May 17,2010 By Hand Delivery Susan Sawyer,Administrator North Andover board of Health 1600 Osgood Street North Andover,MA 01845 Re: 657 Forest Street,North Andover Septic System Design Dear Susan: Enclosed you will find 3 copies of revised septic system design plans for 657r Forest Street,North Andover. These plans have been revised to address the comments in your review letter dated April 16,2010 as follows: /1. On May 11,2010 a percolation test was successfully performed on the property. The percolation rate of 5 minutes per inch was obtained and the system size has been revised accordingly. 12- The legal boundaries of the lot have been added to sheet 1 on a 100 scale insert. ,,,3 The designers statement has been added on sheet 1 of the plans. 4. proposed 102 contour has not been added since the 102 contour will stay in the same location as it exists before construction of the new system. If you look at the profile view on sheet 2 you will notice that the proposed grade over the system blends in with the existing sade at an elevation lower than 102. pot grades have been added to the plans. .There are no leaching facilities within 100 feet of the proposed well with the exception of the existing system which will be abandoned.A dimension from the well to the existing leach field has been added and General Note# 16 has been added. L,7!_The effluent filter was not required and has been eliminated on the revised plans. S/ The effluent filter has been eliminated and therefore the cover over the tank is not required to be at grade. sieve analysis is not required now that a percolation test has been performed. 10 note regarding the wetland delineation has been added to the plan.(General note# 14) A statement has been added to the plan regarding the watershed district.(General note# 15) If you have any questions you may contact me at 508-3284633. Sincerely, Beni=C.Osgood,Jr., .E. indicating the required annual maintenance in accordance with 310 CMR 15.227(7). NA 3.2 8. If an effluent filter is proposed in the septic tank the access manhole cover is required to be at finish grade 310 CMR 15.227(7). 9. Please submit the results of the sieve analysis in accordance with D.E.P. guidance policy. 10. Please indicate the company or individual and the date when the edge of the bordering vegetated wetland was determined. 11. Please provide a statement indicating whether the property is, or is not, within the designated Watershed of Lake Cochichewick(NA 3.2). Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Since y, Susan Y. S er, RE /RS Public Health Director cc: Forest Realty Trust File .c e l°!J t1�J.;IJL9.ltJ ' e e f NORT1�� Town of North Andover 3rpae�f`�c+,,"�e��L Invoice No. 5/6/2010 0 � no Benjamin Osgood,Jr., Health Department Bill To P.E.-Senior Engineer 1600 Osgood Street SSACHUSE Address c/o:Pennoni Associabes,Inc. Building 20;Suite 2.36 Suite 120-100 Bunt Road _Q North Andover,MA 01845 Andover,MA 01810 Web Site.www.townofnorthandover.com Phone 978.749.9929 x3712 Fax 978.749.9920 E-Mail bosgoodApennoni.com DUE UPON RECEIPT ° Total Amount Due $50.00 J Ma 6,2010 657 Forest Street-Missed inspection $50.00 Subtotal Tax $0.00 Total $50.00 r TOWN OF NORTH ANDOVER r Office of COMMUNITY DEVELOPMENT AND SERVICES a? HEALTH DEPARTMENT 1600 OSGOOD STREET;BUILDING 20;SUITE 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.8476—FAX Public Health Director E-MAIL:healthdept@townofnorthandover.com WEBSITE:hqp://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: Site Location: 6b-7 f(z -�- sr:�ef= Engineer: L2,i CI e-4 C--A-rzo New Plans? Yes V$225/Plan Check# (includes 1st submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes 1/ No Local Upgrade Form Included? Yes No `✓ Telephone#: 17 Fax#: E-mail: �05Cr��� c� N��N Glfu t-�2iN G-1�G��a►•vi Homeowner nn Name: u fz y i d{ �►i.T� 2Q si' OFFICE USE ONLY When the submiss'on is complete(including check): )0. Date stamp plans and letter ➢ / Complete and attach Receipt ➢ IX, Copy File;Forward to Consultant ➢ P/ Enter on Log Sheet and Database Benjamin C. Osgood, Jr., P.E. PO Box 71 Amesbury,MA 01913 Tel: 508-3284633 April 6,2010 By Hand Delivery Susan Sawyer,Administrator North Andover board of Health 1600 Osgood Street North Andover,MA 01845 Re: 657 Forest Street North Andover Septic System Design Dear Susan: Enclosed you will find 3 copies of septic system design plans for 657 Forest Street,North Andover. These plans have been designed based upon the soil type found during the deep hole soil testing performed by Richard Tangard. Unfortunately,at the time of soil testing Randy Burley did not agree with the fact that the in place soil was Firm and recorded the soil consistence as being Compact.This result is that this design will not comply with what Randy Burley has recorded for the Town of North Andover. Both Richard Tangard and I disagree with Mr.Burley,however to resolve the problem we would like to schedule a percolation test next week to eliminate the disagreement.Please contact me as soon as possible to schedule this test. If you have any questions you may contact me at 508-328-4633. Sincerely, Benj;;MI C.Osgood, r.,PE President I Commonwealth of Massachusetts m Cityffown of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal a_ NlassDEP has provided this form for use by on-site professionals and local Boards of Health.Other forms may be used, but the Information must be substantially the same as provided here.Before using this form•check with your local Board of Health to determine the form they use, A. Facility Information = Owner Name ZV=I�,4::P �7 �V 57 7§j;_etAddress Cly StaEe Zip Code FY A z B. Site information Q t- i (Check one) ❑ New Construction ❑ Upgrade Repair IrW 2. Published Sail Survey Available? Yes ❑ No If yes: Year Published Publicalion Scale Soll Map unit ( NT�rtl f � `!'SIV 'hrE f C s4 /SIc V ��jfYA Soil Flame: Soli llmitaliorts 3. Surficial Geological Report Available?❑ Yes ® No If yes: Year Pubished Publication Scale Map Unit Geologic Material �^ orm 4. Flood Rate Insurance Map cr, OD Above the 500-year flood boundary? ((] Yes ❑ No Within the 100-rearflood boundary? ❑ Yes ❑ No rti Within the 54D-yea r flood boundary? ❑ Yes ❑ No Within a velocity zone? ❑ Yes ❑ No LD 5. Wetland Area: National Wetland Inventory Map Map Unt 1 � dame CD Wetlands Conservancy Program Map Ar'Map WIN Mame CD 1-4CD l forml l_doc-rev.10 07 Form 11 —Sall Suitabllhy Assessment for On-Slle Sewage Disposal •Page 1 of B 8 CD m CD N w Commonwealth of Massachusetts a CitylTown of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site information (Continued) 1 2a1�' 8. Current Water Resource Conditions(USGS): �� Mange: ❑ Above Normal lvarrnal ❑ Beiowlormal 7. Other references reviewed: A C. On•-Sko Review (minimum of two holes required at every proposed primary and reserved disposal area) a Deep Observation Bole Number. 08te, Weather 1. Location Ground Elevation at Surfaos of Hole: -�`—� Location (identify on plan): 2. Land Use (e.g..woo nd,agricultural field,vacant lot,etc.) Surface Stones slope(%) �mT���N�7 !✓elf. /�i18 �1�� �L��� Vegetation landlonn PosiNo-n on Landscape(attach sheel) Lo 3. Distances from: Open Water Body quo Drainage Way feet rPossible Wet Area 1 -`� Property Line tet- Drinking Water Well ? i c� Other reel mSic- -77,24 c. 0 4. Parent Material: Unsuitable Materials Present: ElYes No r~ It Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ElWeather+edfFractured Rock ❑ Bedrock LD 5. Groundwater Observed: Yes ❑ If y®S= �Depfh Weeping from Hol Pill Depth Standing Wafer In e (is 24- CD Estimated Depth to High Groundwater: inches lavation m CD Cv i CSO 151onn11.60c•rev,101Q7 Form 11—Soil Sullabliily Assessment for On-Site Sewage Disposal -Page 2 of 8 m m m Commonwealth of Massachusetts Cityrrown of a- Form 'II - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: Redoximorphlc Features Coarse Fragments Soil Horten SDA Matrix:Color- (mottles) Sol[Texture %by Volume Soil Sal[ DopM[i►�1 Layer Moist(Munsell) (USDA) Cobbles& Structure Consistence Other Depth Calor Percent Gravel Stones [fYlalst) A ry /�3l /© YR, z ✓' - y s 3 S 2¢ G � S r Q Additional Notes: m v cn m OD r r, t LO m m m m N i r-I m tsfonml t.doc rev.10f67 Form 11 —Soll Suitability Assessment forOn,SHe Sewage Disposal Page 3 of 8 m m v ' m Q Commonwealth of Massachusetts Cityrrown of lug Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) 3a y t3� Owl 0 W 30 Deep Observation Hole Number: Date Time Wee"W 1. Location - Ground Elevation at Surface of Hole: Location(identify on plan): slope M2. Land Use Surface stones e g.,vroo4��f Yield,vacarrE lol,eta.) 4:9T,_4V1Qo 1VV,'AA41A4& 7,r4_d;4 Vegetation �� landfarm Z0<-? Posftlon ion Landscape(attach sheet) zPossible Wet Area S 3. Distances from: open Water Body . feet Drainage Way feQt reef >10�`� Other - Property l ine feet Drinking Water V�e11 Teel feet OR fG L-;— Unsuitable Materials Present: Yes No 4. Parent Material: If Yes: ❑ Disturbed Soil ❑ Fill Material Q Impervious Layer(s) WeatheredfFractumd Rock ❑ Bedrock A i 5. Groundwater Observed: A `rte F1 { o If yes: Depth VVeeping from Pit Depth Standing Water In We Lo � Estimated Depth to High Groundwater: inches. �,elevation m _ v m M 00 f� � t LO M 0 m N 0 c Farm 11—Soil Sudebility Assessmenl for OnSlle Sewage Disposal •Page 4 of B CD t5torrniiAoc•rev.10107 T) m , w Commonwealth of Massachusets a Cityrrown of Form 111 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-site Review (Continued) Z Deep Observation Hole Number: Rsdoidmorphic Features Coarse Fragments II Horizonf Soil Matz-ba Color- {rrtottles� Sill Texture �'by Volume 801, Sil ob Depth(in.) Layer Moist(Munseit) for ercertt (USDA) ravel Cob leStoStructure Consistence Other (Molat) pth A ry OP BAS 49 .-11 <r Q ------------ I -TH u� Additional Notes: m - m m co ti r, Lo m m CD CD mCA � m m 16form1l.doc-rev.10107 Form I1—5011 Suileblffly Assessment for On-Site Sewage Disposal Page 5 0l 8 m Lo C W Commonwealth of Massachusetts Cityrrown of IL Form II - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: ElPtDepth observed standing water n observation hole W 9 iInches inches Depth weeping from side of observation hole inches inches Depth to soil redoximorphlc features (mottles) A. Z�Inches B. � ches A. B. ca ❑ Groundwater adjustment(USGS methodology) laches Inches W 2. Index Well Number. Reading Date y Index well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material un a. toes at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? v Yes 171 No m co b. If yes,at what depth was it observed? Upper boundary: inches� Louver boundary: 72 inche9 Un m m m CD 1-4CD c� CD 15forml I ADc•rev.1007 Form 7 t—Soil SuiiebMity Assessmeni for on•Sile Sewage Disposaf •Page 6 of 8 m i m '. •. w Commonwealth of Massachusetts Cityrrown of - Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal . Meld Diagrams I iaA th;c-e-npQt for field diagrams. 40 As 28 LF95 F1FIO35 24 1209 Sqt tun 24 A 30 3© a 20 z a 6 i 6 M m Cb rti Lo M m CD m a4 CD CV t � CD m 15form1 l.doc•rev_10107 Form 41 —Soil Sullabikly kssessmenl for Ort-Site Sewage DJwsal -Page 8 of B m I` 1 Commonwealth of Massachusetts QCityfTown of IL kForm 91 - Soil Suitability Assessment for On-Site Sewage Disposal l9i . F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CM R 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described In 310 CMR 15.017. I further certify that the results of my soil evaluation,as indicated In the attached Soil Evaluation Foran, , are accurate and in aocordance with 31 MR 15.100 through 15.107. SignatureW Soil Evaluator Dale c`1 2 C. �xr� ��t3,� C Ile?e5- A or Printed Name of Soil Evaluator r License# Date of Soil Evaiaa Exam QFlame of Board of Ke WFMM Board of Health Note: to accordance with 310 GUAR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testi ng, and to the designer and the property owner with Percolation Testi Form 12, u� m v m m m r` � r Lo m m CD CDi m ' N m Form 11—Sol SuNabilily Assessment for on-site Sewage Qisposal •Page 7 of B ISformlI_doc•rev.1CM7 m m TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES" ,— HEALTH DEPARTMENT 16000SGOOD STREET; BUILDING 20• SUITE 2.36 + ; NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y.Sawyer, REHS, RS RECEIVED 978.688.9540_Phone Public Health Director 978.688.8476_FAX FEB 2 0 2010 healtbdMOgwnofnorthandover.com www.towndriorthanclover.com APPL I CATION FO §EVOICEN'TE' DATE: 07 IZ. M^^AP& PARCEL: LOCATION OF SOIL TESTSr� t -- ,OWNER: ` _ Contact APPLICANT:L 4x Contact#. /► ADDRESS loto CIAP""+ ENGINEER:. : fit"4*6Z ZUs- 379 1 CERTIFIED 801 EVALUATOR: Intended Used Land: Reddential Subdivision SingleFemily Home Commercial . s hi Repair Testing: Undevel�ed Lot Testing: Upgrade for Addition: K. r°t -LkCclllVe . . Yeses No,r.,7X, THE FOLLOWING MUST BE INCLUDED WITH THISFORM ➢ Proof of land ownership(Taos bill,or tetter from owner perrnittl rig test) ➢ 8.5_x 11-Plot cla�n&L�ocation of TestinatrA sei„dicsifeatest cit siteson the plan) ➢ Fee of a4,2 0-per lot for new oo oructicm. This o0vemthe fthimu ,two deep holes and two percolation teats required for each disposal area Fee of X0.00 per lot for repairs or upgrades, GENERAL INFORMATION ➢ Oniy Certified Soll Evaluatorsmay perform deep-holeinspections, ➢ ON Maas Registered Senitalansand Profesafw*ar> sc an designseptlapis- is at-arear --- - ➢ Repairs requiteat least two deep holft and et least one percolation teat,at thedisaetion of the BOH representative ➢ Full pegnr"will berequired for all additional teslevvithin two reeks of testing. ➢ Within 45 days of testing,a scaled plan(no smaller than 1-2-1004"1 be submitted to the Board of Health showing.theloca!<ionof all tests(indudingabortedteets). ➢ Within 60do"of testing soil evaluation forms shallbe submitted. Please Do Not Write Below This L ine \ N.A. Conservation Commission Approval.Date:2 0 _ S T� 0t) y, �-3 % U a P K� S► `.J�e1 � 11 £ignatureof Co vation Agent., �.. T�a w, 1 Date back to Health-,Department: (stamp in): 0.\rj RECEIVED P�o-A s 6 F J 2010 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 9513 PLAN CF LAND LOWED/N WFUNAADOVER,MASS. owner �ccgl J/(�_/]� !(ENNETHMaDOROTHYAR48S g�6ts,+^,yF � Ie E9T ve.s_ �s. TC 7 1( �`�.�j 1 i SCALE/''=410 A/bSCW23,/9M'- e SCOML 62ES FL.S . all. ea Fn '��a e•q 191.Ca 'y�` MO�P/F/ANQOYfl4,AfASS 2GS.e8-rer 99.t-sa e' - G O O w /W es 0 % 3 2 P Lor A-1 s' ® 2826 AG. - I I,,ovt. 00 V 44.9919.P. p 2.Cl2 PG. p e.s..o Sr 9 .// p 1 rs eAl— sel.ol _ S�Mcs µ�R`��y ___ , <� �J7'.`a/e/f�/fes/o7.•��r9�r t e t DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, May 06, 2010 9:55 AM To: 'Osgood, Benjamin C.' Subject: FW: 657 Forest Street- Perc Testing Ben.....Michele can be there next Tuesday at 10:00. If things change,please let me know the day before. Thank you. From: Grant, Michele Sent: Thursday, May 06, 2010 8:39 AM To: DelleChiaie, Pamela Subject: RE: 657 Forest Street- Perc Testing Tuesday at 10:00 From: DelleChiaie, Pamela Sent: Wednesday, May 05, 2010 12:11 PM To: Sawyer, Susan; Grant, Michele Subject: FW: 657 Forest Street- Perc Testing Hi, Monday or Tues. at 10:00? Let me know, and I will call Ben. Vent "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdellechiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com/Pages/index-Website Notes: If copied to BOH Members-Reference Copy Only-no response requested at this time From: Osgood, Benjamin C. [ma ilto:BOsgood@Pen non Lcom] Sent: Tuesday, April 27, 2010 2:57 PM To: DelleChiaie, Pamela Subject: 657 Forest Street Pam, i y DelleChiaie, Pamela From: Randy Burley[rburley@miliriverconsulting.com] Sent: Monday, March 01, 2010 2:14 PM To: 'Daniel Ottenheimer'; Grant, Michele; 'Isaac Rowe'; 'Marianne Peters'; DelleChiaie, Pamela; Sa e Subject: Forest St. Attachments: 657 Forest NA.pdf Please find attached the notes from the soil evaluation today. Because of the high water table a perc could not be performed; there was standing water in the pert hole. Richard Tanguard informed me Ben Osgood took a soil sample prior to my arrival, and is going to send it for a sieve analysis. Ben does not know this because he was not there at the same time I was but, I classified the soil as"compact." In the sieve analysis guidance document produced by the DEP, a compact soil carries a LTAR of 0.15 gpd/sf(regardless of what class the sieve analysis gives as a result). Some one may want to inform him of this, so he needn't waist his time and his client's money by sending the soil out. His options may be wait until summer and re-attempt the perc, design under the 0.15 gpd/sf, or re-test in another area. Feel free to contact me with any questions. Randy Burley Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930 Ph 978-282-0014 Fx 978-282-1318 www.millriverconsultiniz.com rburley@millriverconsulting.com 1 -- e — r • _ C / - - __.. - - - c , , 74 on�2n �"- /Pl L» o r` �J : . R - ter ., l Ot 11 _ r Ci H"1 HI Iii i I IF Ij I � lil � � I I I II I I i I I I � IIIi �. II � � III �� II III IIIIII � I ! 7t , �IIII iillii ! Ilijlll � l_ V(I_ -T iI j � I�Il :� - � �j�j�I��I�I ;I-4-H �IIjI S{I I I 1 r- 1 I 11 P 'f i I--,-tt�--�i I 1 I�✓d I � I I ' I I I I j i jJl I i A I I I i t I '`� 11 I�� i I I°( I' I i i ✓ i � � 'I I L�":. i I I r I ofaR=�, COMMONWEALTH OF MASSACHUSETTS NUMBER �. g@. ` °•� $�� BHP-2010-0577 North Andover FEE Board of Health $135.00 � wu�k HASELTINE, GEORGE --------------------------------------------------------------------------------------------------------- NAME 657 FOREST STREET --------------------------------------------------------- ----------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Well This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires _____________August-1 7, 2010---------- __unless sooner suspended or revoked. May 17, 2010 Board of ---�---- --------- -------------- ---- t Health --------------- ---- ----- ----------------------------------------------------------------- Board of Health Chairman -.J �NQ��t `ire TOWN OF NORTH ANDOVER :*N,�e Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT .f 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 ; NORTH ANDOVER MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.8476-FAX healthdept@townofnorthandover.com www.townofnorthandover.com Well and/or Pump Application (Please print) DATE: 9-11TIZ,010 LOCATION to Drill Well or install a pump: 657 fuf f 54 �JOt A'k P00(Qyerf M Licensed Well Contractor Name and Company Name: .I1;nti S "���� 5 i tk� pe1lf'{lej I 110" 6q3 '1Zgy ikc tt11 Contact Phone Numbers: Homeowner: Cr'Ofr1e W(jitV�;Ae Address: �(y 6���V ec�Sk l� �0�► +�`cI +C� �� 03®�3 Contact Phone Numbers: loos-1105 s 9-4&6 6evy CGII WELLS(to be completed at time of pump test) Type of well: Use: 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-l\bcurran\LOCALS-1\Temp\Well Application.doc Massachusetts Department of Conservation and Recreation 156273 Office of Water Resources 1 6 2 1'7 3 TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (Required), North LL _ .=DL _U_ � West.L. � -e2;1,. _V_ — Address at Well Location: 10 G -7 F0 Property Owner/Client: Subdivision Name: Mailing Address: 1191P yeas City/Town: 1 V 0-k _&d 6Ve M fk Q i 5� City/Town: L47&5oi� Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address available Board of Health permit obtained: Yesq /7 f Not Required ❑ Permit Number �� Date Issued -Fn R 2.WORK PERFORMED 3.WELL TYPE 4.DRILLING METHOD 6. CASING 0 Overburden Bedrock From (ft) To (ft) -Type- Thickness Diameter to ® 0 ® ® ® [91 o 40 . .oTo _7 67 jj Extra 5.WELL LOG OVERBURDEN �'❑❑ Water Loss or Drop in y ti❑❑❑ LITHOLOGY Bearing Addition Drill Fast or Zone of Fluid Stem Slow . 7.SCREEN From (ft) To (ft) Code Color Comment Drill Rate Y / N Y / N F / g From (ft) `Tfl(ft) Type Slot Size Diameter Y Y F � '\ ❑❑❑ - - - ❑❑❑- - -- Y / N Y / N F / S - ❑❑❑ - - - Y /.N Y / N I F / S g• ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL. Y / N Y / N F / S,, From(ft) To (ft) Material Description Purpose Y / N Y / N F / S._ El 1:1 11 AWKI AC NORTH Y Y F / S' ❑❑ - ❑❑ HEALTH DEPAR MENT Y / N Y / N TJ .S. w ❑❑ ❑❑ Y Y / N' .F4S ❑❑ 1:1 EJ WELL LOG BEDROCK Water Drop in Extra Extra Visible Loss or #of 9. SITE SKETCH LITHOLOGY Bearing Drill Large slow Fast or Rust Addition Fr From(ft) To (ft) .Code Comment acture Zone Stem Chips DRrill 11 Rate Staining of Fluid per foot Y / NY / N F Y /.N Y Y / NY / N' F / SY / NY / N Y / N Y / N F / S Y / N Y / N Y./'N Y / N F / S Y / N Y / N Y / NY / N F Y Y 04- / Y_%`NY / N. F / SY / NY / N L'l� Y-/ N Y / N F / S Y / N Y / N fE,}rjL Y ! N Y / N F / S Y / N Y / N Y / NY / N F Y / N- Y / N Y / N Y / N F / S Y / N Y / N 10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATER LEVEL(ALL WELLS) Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below Date Method (GPM) '. (hrs'S min) (Ft. BGS) (hrs&min) (Ft. BGS) Date Measured Ground Surface (ft) 12.PERMANENT PUMP(IF AVAILABLE) 13.ADDITIONAL WELL INFORMATION Pump Description ® � Horsepower t fo� `DevelopeC/ N Fracture Enhancement Y / N Pump Intake Depth Jj& (ft) Nominal Pump Capacity (gpm) Disinfected/ N ��S�u��rfaj�cc'e Seal Type ❑�2��r� 14. COMMENTS Total Well Depth`T Depth to Bedrock"�.J 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 compl,e and correct to the best of my knowledge. Driller �'11ri t Supervising Driller Signature: Registration #: 1 16 1 41 Firm: ?± Date Com fete: ' Rig Permit#: to NOTE: Well Completion Reports must be filed by the registered well.driller within 30 days of:well completion. BOARD OF HEALTH COPY Well Completion Report Codes Section 2 Section 3 Section 4 Work Well Drilling Work Performed Type Method Performed Code Well Type Code Drilling Method Code Decommission DC Cathodic Protection CTPR Air Hammer AH Deepen DP Domestic DMST Air Rotary AR Hydrofracture HF Geoconstruction GCON Auger AG New Well NW Geothermal Closed Loop GTCL Cable Tool CT Repair RP Geothermal Open Loop GTOL Casing Advancement CA Replacement RE Industrial INDS Core CR Injection INJC Direct Push DP Irrigation IRRG Drive and Wash DW Monitoring MONT Dug DG Public Water Supply PBWS Mud Rotary MR Recovery RCVR Reverse Rotary RR Test Wells TSTW Sonic SN Section 5 Section 6 Overburden Casing Lithology Overburden Overburden Overburden Bedrock Type Thickness Name (OB)Code Color Color Code Bedrock Name (BR Code) '" ;_ Code Thickness (NO CODE) Artificial Fill AF Black BL Amphibolite AM Certa-Lok GTL Schedule 5 Boulders B Bluish Gray BG Basalt BS Fiberglass FBG Schedule 10 Clay CL Brown BR Conglomerate/Breccia CG/BR ti f Galvanized Pipe GLP Schedule 40 Coarse Sand CS Dark Gray DG Diorite DI f HDPE HDP Schedule 80 Cobbles C Greenish Gray GG Gabbro GB NSF,Coated,Steel., NCS Schedule 160 1 k?4a41:u�t. 1 .A ! Fine Sand FS Light Gray LG Gneiss GN � ,.� r 3 PVG ` PVC SDR 13.5 Fine to Coarse Sand FCS Reddish Brown RB Granite GR ,,_' _.w "�tatnlass$t8e)"_ ._SST SDR 17 Gravel G Yellowish Brown YB Limestone LS Steel STL SDR 21 Medium Sand MS Marble MA SDR 26 Organics 0 Quartzite QZ SDR 32.5 Sand&Gravel SG . Rhyolite RH SDR 40 Silt SI Sandstone SS 17# Silty Clay SICL Schist SC 19# Silty Sand SIS Shale SH Silty Sand&Gravel STSG SlatelPhyllite SUPH Till T Pegmatite PM Section 7 Section 8 Section 10 Annular Seal/Filter Screen Annular Seal/Filter Pack/Abandonment Purpose Method Screen Type Code Pack/Abandonment Material Code Purpose Code Method Code Carbon Steel CST Bentonite Chips/Pellets BC Fill FL Air Blow with Drill Stem AB Continuous Wire PVC CWP Bentonite Grout BG Filter FT Air Lift AL Galvanized Wire Wrapped GWW CementlBentonite Grout CB Seal AS Bailing BL Perforated Pipe PFP Concrete CT Constant Rate Pump CR Pre-pack PVC PPP Sand SD Variable Rate Pump VR Pre-pack Stainless PPS Native Material NM Slug SG Slotted PVC SLP Stainless Steel Vee Wire SSV Stainless Steel Well Point SSP Section 12 Section 13 Pump - Description Well Seal Pump Description Code Horsepower Surface Seal Type Type Code 2 Wire Constant Speed Submersible 2WSS 1(2 20 Cement CM 3 Wire Constant Speed Submersible 3WSS 3l4 25 Cement/Bentonite CB Constant Speed Submersible Turbine CSST 1 30 Concrete CT Variable Speed Submersible Turbine VSST 1 112 40 None NO Jet JET 2 50 Line Shaft Turbine LST 3 60 Centrifical CENT 5 75 7 112 100 10 125 f .t 15 150 �. -- _ -'200