HomeMy WebLinkAboutMiscellaneous - 781 FOREST STREET 4/30/2018I
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Mass- isetts Department ofr Environmental Mar ment
130229
TYPE OR PRINT ONLY We 1 CoWa
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1. WELL LOCATION 70S -(OPTIONAL) 'LAVUDE LONGITUDE
Address at Well Location: Ps '
Property Owner: /�
Subdivision -Name: f li s
,-
City/Town: f � 1 ) /of. < .. City/Town: �c %�..�c, ✓�C �--. '. .
Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available
Board of Health permit obtained: Yes ElNot Required tom' Permit Number Date Issued
2. WORK PERFORMED
3. PROPOSED USE
4. DRILLING METHOD
❑ New Well O.Abandon
❑ Deepen ❑ Recondition
❑ Replace ❑ Other
❑ Domestic ❑ Irrigation
❑ Monitoring ❑ Municipal
❑ Industrial ❑ Other
❑ Cable ❑ Auger
❑ Air Hammer ❑ Direct Push
❑ Mud Rotary, ❑ Other
5, WELL LOC
(r
W
F—
Q
Permeability
High
Low
Unconsolidated
Consolidated
6. SITE
SKETCH (use permanent landmarks with distances)
From (ft) To (ft)
>
_m =
v `o
a
y
a
`
m
Other
Rock Type
7 WELL CONSTFIPPTIi0N,
<
8. CASING
Total Depth Drilled
Date Drilling Complete
From (ft) To (ft) Casin4 Type and Materia! Si O.D. (in) Well Seal Type
;gnlmm OF RTH ANDOVER
S� SCRIEEN f'' HEALTH
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
1o. FILTER PACK I GROUT I ABANDONMENT°MATERIAL.
11. ADDITIONALWELL INFORMATION '
From (ft) To (ft) Material Description Purpose
Developed? ❑ Yes ❑ No
.Fracture
Enhancement? ❑ Yes ❑ No
Method
Disinfected? ❑ Yes ❑ No
r
' f
''%,f
f�f u_`' -p- ? �--• zee_
' j/
. `WELL
TEST DATA (PRODUCTIO W ELLS)
13. STATIC WATER -LEVEL:{ALL
WELLS)
Yield Time Pumped Drawdown to Time Recovery to
Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS)
Date Measured
Depth Below
Ground Surface (FT)
U. PERMANENT PUMP (IF AVAILABLE)
15. NAMEADDRESS OF PUMP INSTALLATION -COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
��` G•.
17.'WELL DRILLER'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 to the best of my knowledge.
SDriller: Zee 'Jupervising Driller Signature: Registration #J
Firm: f tl . / �f ,` .�-`' Date:;` Rin Parmit # I I I I I
KVOT'E: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH CONY
PZo�JA L D Eiv� 1�0
L T - T ST
NttiRC�4'14,1973
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ASSORpT1oN AREA
S'
30P
ABSORPTION t BED END SECTION
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DISPOSAL SYSTEM PROFILE
Em
EA
ABSORPTION BED PLAN
�. 6k" rt:1 Otj or- Pisr> .'x0" rgL-LOW GRA0&_
OBS. HOLE
12" TOP
50i(.
5 �V' f t.AC iet
TiLL
PERC. HOLE
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PERC RATE
ca, m("pia 1t'D124p
O PERC TEST
TEST DATE
,5/2-4h3
Ag
'L\ Commonwealth of Massachusetts -�
City/Town of NO, ANDOVER
System Pumping Record 1 2006
Form 4 OCT 3
M
I
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided hefe.-Before,using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
4:1
rnaen d
A. Facility Information
1. System Location:
781 FOREST ST.
Address
NO.ANDOVER
City/town
2. System Owner:
RONALD EMRO
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping 9/26/06
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Ja No
5. Condition of System:
6. System Pumped By:
Benjamin Shute
Name
J's Septic & Drain
Company
7. Location where contents were disposed:
MA
State
State
Telephone Number
01845
Zip Code
Zip Code
2. Quantity Pumped: 1000
Gallons
gjj Septic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
a
9/26/06
igna ure auler Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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Commonwealth of Massachusetts T C IVSD
F City/Town of NO. ANDOVER C , ZQ10
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
�M HEALTH DEPARTMENT
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
r ray
renes ��
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
781 FOREST ST.
Address
NO.ANDOVER
CityfTown
2. System Owner:
RON EMRO
Name
Address (if different from location)
CityfTown
B. Pumping` Record
1. Date of Pumping '
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [Q No
5. Condition of System:
6. System Pumped By:
James H. Currier
Name
J's Septic & Drain
Company
7. Location where contents were disposed:
GLSD ��
of Hauler
MA
State
State
Telephone Number
01845
Zip Code
Zip Code
— 2. Quantity Pumped: 1500
Gallons
5;J/Septic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
9/3/10
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1