HomeMy WebLinkAboutMiscellaneous - 600 SHARPNERS POND ROAD 2/1/2016 (2) NUMBER FEE
THE COMMONWEALTH OF MASSACHUSETTS
of .................
This is to Certify that ....Vl�x .... .....................•...
NAME
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ADDRESS
IS HEREBY GRANTED A LICENSE
For .... .. ... -
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This license is granted in conformity with the Statutes and ordinances relating thereto, and
—D<5r(Z , ,31 Q(Do / unl d d or revoked.
expires..................................;��------------------I------------- ess sooner suspQn e
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FORM 43.9 HOBBS&WARREN
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�,�sa, •• jcti BOARD OF HEALTH
SACMus W✓
NORTH ANDOVER, MASS.'
APPLICATION FOR WELL AND PUMP PERMIT
Permit # � -<.<.; _ Date r"
A permit is requested to: drill a well L,•° install a pump
LOCATION: n, 4", /"1 eo-s t- .0 F���J Lot
Owner Address Tel
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Well Contrctr ® � m t�cCCe d Add. Tel
Tel
Pump Contrctr Add. G f ��
� � �.� �`� Tel
WELLS (To be completed at time of pump test. )
Type of well Use
Diameter of well Size of casing
Depth of bed rock Depth casing into bedrock
Seal been tested? Yes (_) No (_) Date of test
Depth of well Water-bearing rock
Depth to 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 well seal
Date
Signature of pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector
Board of Health
A /1w�
OCT 2 5 2001
BOAit t i
NOt H" ANDOVER HEALTH—
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APPLICATION F65R WELL 'AND PUMP PERMIT S
Permit Date_ ' ara
A permit is requested to: drill a well; install a pump
LOCATION: ��l l ter 4.1--s pap Rd Lot # U4 ���� ��✓�� �`
Owner 4 ��,� i' Address , - �Z Tel
Well Contrctr d�la�a� ��s t�t��c°d Add. s �r�,-�, Tel ?-f'"i°' b i
Pump Contrctr LR�) ��ur� P�w� Add. s'f C r���,-n s ®l Tel ?� ,f Ff t t'� '
ti-- rrraciric�c
WELLS (To be completed at time of pump test. )
�I
Type of well ' Use
! '
Diameter of well L Size of casing
00, 01
Depth of bed rock Depth casing into bedrock (7 /V/
Seal been tested? Yes ( �' ) No (_) Date of test "w. ,
Depth of well , Water-bearing rock "
Depth to water 2.0 .0 Delivers GPM for
(how long?)
Drawdown -?2S7 feet after pumping ,, hours at � GPM
u
Date of completion ,d , ,C)/
gnat "`re 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 well seal
Date
Signature of pump installer
.x
Date water analysis report submitted to Board of Health
r
Plumbing inspector Wiring inspector
Board of Health
Massachusetts Department of Environmental Management A ,�
Office of Water Resources 4
TYPE OR PRINT ONLY Well Completion Report
1.WELL LOCATION GIPS (OPTIONAL), LATITUDE LONGITUDE
Address at Well Location ���? ` � )N t��„� �� /'r:}°r � 1; � " a�, ,r)
property Owner:
Subdivision Name: Mailing Address kt
� ti� a " e .u. C:k,
City/Town: fi
Y � � � City/Town: A,/
�✓ ' r� i � - /,a-/
Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address available
Board of Health permit obtained: Yes C Not Required ❑ Permit Number <` D ate<Issued �
2.WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD
❑ New Well ❑ Abandon 0 Domestic ❑ Irrigation ❑ Cable ❑ +Auger
❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push
❑ Re lace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota ❑ Other
S.WELL LOG W abi
Permelity Unconsolidated Consolidated `6.SITE SKETCH(use permanent landmarks with distances)
W
H a a m A
Q c0 ro a
From (ft) To (ft) Hign Low m Other Rock Type � .;f
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7. WELL CONSTRUCTION 8. CASING
Total Depth Drilled From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Completet
9. SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PAC ROUT ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
Developed? ❑ Yes ED No
From (ft) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yes C1 No
Method
Disinfected? Etf 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)
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Al "�
, .,.
14. PERMANENT PUMP(IF AVAILABLE) 15.NAME/ADDRESS OF PUMP INSTALLATION COMPANY
Pump Description Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16.?COMMENTS -
17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision,,according to applicable rules
and regulations, and this r`ebort is complete affg corfoct to°the best of my knowledge.
Driller: �.. LZ :41 Supervising Driller Signature: r� `r �`
p 9 g Registration #:I I I I .
Firm . J x " _ r H Date: rr° r ° f Rio Permit #:
NOTE Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY