12 BUENA VISTA AVENEU .. ,.. a ..w<r «n-. .ga ag4trf�f*'l,�aa. �,, .w., ,...K 4+.�.•e-tee:-.+;s,e e:w+' ,
r 'CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
+ 4 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 0 197
TEL. 978-741-1800
FAX 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
f
WELL CONSTRUCTION PERMIT
Location 12 Buena Vista Avenue
Owner Nhan Kien Hoang
Address 9 Marion Road, Salem, MA.
This permit is granted in conformity with the statutes and ordinances relating to
well permits.
Well construction permits are non-transferable.
This permit shall be on site at all times that work is taking place. Permit shall
expire one (1) year from the date of issuance unless revoked from cause.
This permit does not constitute a Water Supply Certificate.
Permit # 2-03
Date issued 7/30/03
(Artesian well) (Brewer Pump & Supply Co. — Reg. #655) /� ---
Health Agent
*Please be sure well is located atleast 25 feet
from the road driving surface.
jut 21 03 01:24P Joanne Scott Salem HUH 979 745 0343 P• 2
CITY OF SALEM, MASSACHUSETTS
BOARD OR HEALTK
• 120 WASHINr.TC
SALEMN STREE
O T, 4TH FLOOR
TEL. 978.741-1800
FAX a78.745.03A3
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
Well C struction Pe i oplicatron
1Date:]t14D--:e Fee: $100. Check payable to the City of Salem (no cash)
Location: J t Salem, MA, 01970
Address,
Owner.
]4A c. KtGJ k � � 6/e-
Type ofwelL �
_/>7 ' /A'� Well use; Pum Contractor: ��
Well Contractor. 1g tew e t cue// S apiy fi9/n�
Address:, 3 P Address:i° Yur •I"- Anzne rN✓1 — Phone:f'fIi/1�
Phone: Q-7j) JSS'- HU?T vlo�y
Reg. #: (o s S' °Nr a. /mi-ftl7S/2.
Have abutters been notified? (y) Howl
to the space provided below(Or on bacJd sh the IMMOn Of the proposed Welt in relation to
existinand use viidilnp(200 feet of the propsed above or below osed Wamund structures.cation, Wh ch rrepMSentVon f avisible
tential SOurce Of rior and current
contaminailon.
HguSe 10
s�
There is no fee for monitoring wells but a permit is required for Installation.
U.O.H.use only. Check# check date; Permd#:
well oW pert Appi revised 41129102
N \T
N 47.24'37 {y -�
�, TG o36
± cam . RESOLRCE AREA 183.Qp� ��JERMM REALTY .TRUST - N
°° .P,°
cL ��9 LOT 57B
Nb �T�
�.,
Y ,� J \ NCZEI LL PROPOSED u
9=•a 'SILT BARRIER m
W ♦♦ � m
NO-BUILD 7z
tr
I�f loo rry \o Vis..: \\ \\
IGAR
o
SLAq
101
re y. \J T �i5ly__ `_ - 61 . CF�FLR.- 1O3' r
PROPOS
SEWER SERVICE 5_
w \e: \ \ LINE OF
W-- �
`'SAyy FS` I �IOO FT. BUFFER. _-.. .
100.3-° TA
—°'
1 - \FS
i�.,,iia;. '�'- ^r�aa�'':;P'� ����^�T�`'�`aAY`xt•s.T""r� y«°.,"`t.. ,,.x,.3�. r < a�'i,. 20-
CITY OF SALEM, MASSACHUSETTS a
BOARD OF HEALTH
• i 120 WASHINGTON STREET, 4TH FLOOR
— SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. _JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
Commonwealth of Massachusetts
City of Salem
WELL WATER SUPPLY CERTIFICATE
Location 12 Buena Vista Avenue
Owner Nhan K. Hoang
Address 9 Marion Road, Salem
This certificate is granted in conformity with the statutes and ordinances relating
to water use certificates.
Certificate # : 01-03
Date issued : 8 / 26 / 03
Salem Board of Health recommends yearly water testing
For coliform bacteria, nitrate and nitrite.
Health Agent
Jul 21 03 01 : 24p Joanne Scott Salem HCH 978 745 0343 p. 5 'i
ro * CITY OF SAL-EM, MASSACHUSETTS
HOARD OR HF_AI 111
^ 120 VVA5111N(; ON Si ktv P:I', 4'rH I L60R
SAI rN, MAO1970
Tf,i... 978-741 1000
AX 97$-1115-0-44:3
Ne
dA�l I V USQv"CZ. J!7.
M n)'ufe III,Al 'III AIANI'
Well Water SuDl2ly Certificate ARRlication
The issuance of a Water Supply Certificate by the Board of Health shall
certify that the private well may be used as a drinking water supply, A Water
Supply Certificate must be issued for the use of a private well prior to the
issuance of an occupancy permit for an existing structure or prior to the issuance
of a building permit for new construction which is to be served by the well.
The following must be submitted to the Board of Health to obtain a Water Supply
Certificate :
"copy of the Well Construction Permit
"copy of the Water Well Completion Report as required by the DEM
Office of Water Resources (313 CMR 3.00)
*copy of the Pumping Test Report
`copy of the Water Quality Report
------------------------------------------------------------------------
Location of wellf— 2 Ite"" Salem, MA.
Owner of pf upehy: N 4A N1 K. LONLr TeA 71f�i f.S 77�
Owner's address: Ul g 7�
Number of bedrooms:_
Date:26,�1u�, --b3
-------------------------------------------------------- -------------------------------------
B.O.H- use only Permit # •
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
a
120 WASHINGTON STREET, 4TH FLOOR
a SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
WELL CONSTRUCTION PERMIT
� c
Location 12 Buena Vista Avenue
Owner Nhan Kien Hoang
Address 9 Marion Road, Salem, MA.
This permit is granted in conformity with the statutes and ordinances relating to
well permits.
Well construction permits are non-transferable.
This permit shall be on site at all times that work is taking place. Permit shall
expire one (1) year from the date of issuance unless revoked from cause.
This permit does not constitute a Water Supply Certificate.
Permit # 2-03
Date issued 7/30/03
(Artesian well) (Brewer Pump & Supply Co. — Reg. #655)
Health Agent
*Please be sure well is located atleast 25 feet
from the road driving surface.
CITY OF S,4LEK MASSACHUSETTS
- BOARD OF.HEALTH -
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR '. - HEALTH AGENT
Salem Board of Health Pumping Test Report
Name of well owner: /%/Q cyrjLkA n/l4- Address: I Z —Ru E rl#q V-1-STAAVE
I
Wall,location (referenced to:atleast hvo perms ent structures or landmarks):
� �ift'Ozv1 ?t. 1.nr,A !)R.:.a�Rly'
Date pumping test was performed;
r
Depth at which pump was set for the test: 30a:. _
Location of the discharge line: toj4Am1pF 13 A AUK i I JG- _
Static water level immediately before pumping commenced: 113 t _
Discharge rate: i0 CrPM (if applicable, time the discharge rate changed) N4f
Pumping water levels and respective times after pumping commenced:
' :2
Maximum drawdown during the test:
Duration of test: a) pumping,time:_51 hoof?
f b) recovery time during which measurements were taken: .
.f; 5779r/C. a S- A4 f j e S QA"f CCS e)Al _
Recovery water levels and respec ive times after cessation//of pumping: _
-
Reference point used for all measurements: "Tn rQ swell _
Please fell out form completely and return to the Salem Board of Health
along with the Water Well Completion Report. Pump test report is a
requirement prior to issuing a Water Well Supply Certificate.
MassachusetIt� Department of EnvironmentalManagement 124329
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS (OPTIONAL) " LATITUDE '252 NI-1 -` LONGITUDE -LL m®^
Address at Well Location: IZ B-16 ASA ) STA DF.Property Owner: h A)O YL)
Subdivision Name: A//A Mailing Address: 12- r5t-4t A>l9 ) S-rA ,,D f
CitylTown: '581 n1 t 1�I�) /���� Cirylrown: 15A /-L „1 V\ � 1C/70C' Z
r i
Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address available
Board of Health permit obtained: Yes 13?1� Not Required ❑ Permit Number 2 - O 3 Date Issued 9-30-03
2. ORK PERFORMED • ° ' r 3. ROPOSED USE - 4r DRILLING METHOD;:,
New Well ❑ Abandon Domestic ❑ Irrigation ❑ able *=. az'EI Auger
❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal CIS Air Hammer r 0 Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota _ '--❑ Other
5. WELL LOG ¢ Unconsolidated Consolidated 6.SITE SKETCH (Use ieimaneni landmarks with d stances)
W Permeability ,� m
From (ft) To (ft) High Low O .0 -0 1 m. Other Rock Type Z � 2
8 3 s t EDre 645C-1 1
lU ;�tz F-IfO It
\ C
b O
.1 n —sUrcrJA V ISTA PJ E
7. WELL CONSTRUCTION. x : ' 8. CASING tF •^ . T» k t«
Total Depth Drilled J 5 From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete 0 A0 .5 � '�.G ,✓E J`/ljld�
t03
9. SCREEN
a,n
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
1 'FILTER PACK/GROUT-/ABANDONMENT MATERIAL=: ;rshy a_w3: 11 rADDITIONAL`WELL`INFORMATION;
'aDeveloped? E3Yes EKNo
n,
From (ft) To (ft) Material DescriptioPurpose
Fracture
err Enhancement? ❑ Yes' CeNo
` r Method
Disinfected? W111yes ❑ No
12.WELL TEST DATA(PRODUCTION WELLS) 13. STATIC.WATER ILEVEL (ALL WELLS) ,
Yield.NTime Pumped Drawdown to Time Recoveryto Depth Below
Date Method (GPM) '(hrs & min) (Ft. BGS), (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
2 U C-l- \.90 m `j a'f 1. 1 30 3 -2 -a 3 30
4 d
14. PERMANENT PUMP(IF,AVAILABLE) ; : ass& ' ,. "r " :'&: 15 NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description sr;.�11�L96 Horsepower ( S M E
Pump Intake Depth -'3201 + (ft) Nominal Pump Capacity (gpm)
,
16. COMMENTS
17. WELL DRILLER'S STATEMENT IThis 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.
Driller: /1r tiff`seRr" LA6c5ATE Supervising Driller Signature: Registration #:Id 161 S1 SI
N 7
Firm: .k�WEg Date: F- X-03 Rig Permit #: I OI /1 06
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
I
_ A 7�amB1� n_.T I��aL 1-013:!3'0233 l'�812^c:'E2 111.3=artP, �1P.1
Box 1192 Stadler Street, Belehertown,MA 01007
(413)-323-'7134
Name: Brewer Pump,& Supply, Inc. Sample Date: 8-11-03
Address: P.O.Box 535 Report Date: 8-15-03
So, Barre,N1A 01074.0535 Collected By: John Brewer, Jr.
Sample Location: — . Type Supply: well
Nhan Hoang Sample No.: yQAA.L 9657 with SP 305,1
12 Buena Vista Way Lab ID#: M-02454&M-MA 138
Salem,MA 01970
PARAWTER RESULT MAX RECONN ENDED LEVEL
Total Colifarm Bacteria Absent Present or Absent
For the item tested,this sample was found to be whbin ac;,eptable levels for E.P.A. Standards.
QUARSI-N ANALYTICAL 141aa2sge088 08!22,102 11,42am P. 002
FRUTA SPFCTPUIt ANALYTICAL 0 1) E 22 20Ji; ' D:_IiST. Ip'.:6!Pd0. 5510232t2d F t
Flrul Repos
Report Date: ❑ Rcbaued Repon ;
22-Aug-03 OBA4 Revised Reps:
SI E(9RUM ANAIYTICA 4 INC,
Fremriat
NANIBAI,TECIINOLIICY
Laboretory Report
Quabbin AnNyucal Lab
Stadler Stray P.O.Box 1192 Project 12 Buena Vista Way-Salem,MA
Bekheltown,MA 01007 Prokct#:(now]
Atm: Dave Freddenburg
' ]p Client SamdeID HWj Due no Date Recolved
SA00860.01 SP 3051 Driaking water 12-Aug-01 00:00 12-Aug-03 10:50
I attest that ail information Goatakod Witbin stria roporthas ben reviered lot accuracy and eWded Against all quality comm]
raptkemesu outlined in cede applicable rnpdsod and moa the segaiteeentn of NBLAC.
710 reW may aur be reproduced,except in fu0,without W611en approval from Sfeetrum Amlytitsk Inc.
Mumd m sel Cestifiaotion N M-MA138 Auo mmd by:
l` etiml 61 PH-0777
Flmib#W600 Naotpe4 please?late. Data contained within this report has undergone
Maine#"A primary validation but zany be subject to change grading Cuul
New Hampsbim M 2538 #� validation and QC review.
New York ;11393 s4
Rhode Ialaod#98 ;
USDA#S-3143.51
The fgfseased"contained to rhes trnasmusioa it intended for the
ealurito urs df rhe brditdd age numed above and is privileged and
cWjdeVial, !f yos ass nae the inronded recipient,you are hereby
nosjllea'dme day form ofelissemtnoNgn of drir womuAtcaeion iv
shady pr ehibUad. ifyou lave received dW nonrminion in error,
plane Wzusoaely notd :Oecrrum Anatyrieal at(413) 78969018.
ENyIAQNNiMdLAP'WIF4
I!.41ur-rcn Drive.Afaams Mtasxlaadis 0100I .1.800-_39-9115 .4I1799Mfl Fu 413-1R9.1tfl6
Ingo I of e
_ _ ___.__.____ uar rc.•aa iltt.:;=_m F. F:,:"3 ',
.ROM 371;:''=UM .!(nL'Tl�i �f;li 8 22 '003 II 'e7/ST
Simple TdanefieRtgm Client pmiael b MAIM Q12mm2amm Received
AP 3851 [none] DiWdag Wahl• 12-Aug-03 W10 12-Aug-03
SAOOUD.OI
•ffayym 0 Dawfim d6fla4JW J4WWd A
AlyVd 9iffA ,Cpryip R
VOIAd1t Ofglul c'COmp"B&
SIe.I PvramDll;jDvu4;f A,muAL• Pmpww by rotten!!VOittilb
ARm11C BBL. 10.0 ugA I FSA 3243 11•Au443 14•Aagg13DN"7 dm
Amybnibile BRL 1.00 usm
Sam"" GAL 0300 uv I
GromokowN GAL MOO ugA
Gro11wa81o7v1nfo1.lge GAL os"W
GtanOd d lolonlnivaap HAL 0.300 wgA
Bloa2oPolm GAL. O.Soo ugA 1 • . , :
BmlmlluNw - HAI. 0300 ugA 1 ,. ••
1.11ua11o0t IMEKI GAL 10.0 ag/,
rAILVIlmamle GRL 0.300 ugA I ••
fao-uylbvwm GAL 0.500 A 1
tat•Gwrytbainga Gu 6306 ayl
Cubon48w111de GAL 0500 ugA 1
Colt"tamp&d ide GRL O.s00 ugA
cmdrobwamo an osoo Usti
chlorbadma GRL 0300 Owl 1 ,
L"blomform GAL o3vow ! ,
cwwomabw GAL 0300twi t
2.Clbrototwm ARL 0300 ugA 5 ,
4Lbloromlwaa on 0.500 ngA _y • ,
f,P•DgaOmo-S ebfetapopme BRL 0.900 agA I
DitrorooaAloronethw
GAL O•s00 1 ,
f,2•Di6famaleaenlaOA) GAL 0,500 go
D hloomllduna GAL 0.500 tgn i
12•DitDlaObaotau BRI. 0:500 ve 1 • '
41 OaDlaobaaav BRI 0300 agll 1 ,
l,44p0bc*ww" BRL 0.500 u01 I
DNAta{aodf�0aoylaatirtbwa(pro1n63)
GAL O.S0y0:wgA 1
11f�1MMW,YO,' DAL 0300 WCA I • Y • •:
I,bDim10a0atSaaa GRL *Soo ur1 1 • • ••
1,1.1)idl�loeUaac'. GAL 0,50044 1
ala.f,2•D'eDldagafbMe - GRI. 0300 vi I
wm+1,2•DioMuwllmm GAL 0300 wo I - -
i Z•t)1611ma�yp R BRL 0•S00 41 1
1,1•giohloropropaXa GRL 0360 ugA 1 • .
E,2•DirAlDropropalo BRL 0.3001441 1 , . ,
1,1.OIdIkfOptapae BIL:. 0300 ugA 1 , • .
ahe1,1-Didliolaprapea>: GAL 0.300 usn 1
x=w1,3 DGSlIDMcapm BRL 0.300 ugA 1
E*Yb =m BRI. 0300 ogA 1
Haadllalokwimn GAL O.Am awl 1 ,.
2-Iicaawc(MBK:' BILL 10,001 t ,
131ie bNrowry/ep/u LsaN nAf wkbbtu rrbnkd>ffmtw'►m14beMwpa.
'AapmmbL DemmleA Llail! ARL-2Wm Aapw ng Lbaie page 2 of li
ra seea�n�eeear+>:.•-s-r';+�.:.,>:,�',-*.!.e-rmavaa+r.�•^r:".•>s.++—...v.rrr�-_....,;.-.rr-,.._.••:v.--.., -- �r.;�.r.•�.e.;.•. '
�. .--. - -- —... .•a cc:aoeaa I�gIZ�/(]d 11142fim P. DH�
fP';M 3Pt;'TkUN ANALYTICA. IFRI) 0 22 2 X3 10'2b/S'. 1( 26/h10 5°'P2
511I11L14Z017110ib00 Clleat Proiett 0 MAA s'gy etiaa DateRime Received
SP 3052 Inose) 1?riuld2g Water IT.-Aug.03 ftoo U-Aug.03
SA00860.01
AMD#" _ Rauh eRb"atta DRda_ MWIMWJ a2 IMtPg"d Aaebrtd Dsrri Aaaftstow
VdwleOrpl e:Cornpo>,teda
1241 uroobtr-Qrsawk COntoowada hopored by tnaibod v wl"
loopo9y40"" SOL MOD ugh I
Mlirpng0Moi0oM. BIL 0.50044
Mdhyl tork"l OUT ORL 0.500 094 I ,
4•54e6.yi-2-Wim me(MLSXl SAL 10.0 ugh s ;:
Mnhgleao ddwkW BILL 0.500 a%A
>hwhmaae BRL 0.500 V44 I r
a.Propyibeauee BRL 0.500 W 1 _
gtywme SAL 0.500 pail r
1,IJ,2•TdmcW rorthma HILL 0.500 ug4 1
I•I.2,24eemeAwoethane BRL 0.50D uy1 1 ,
rateashloro.dt.rro - BILI" 0.400 USA 1
Talmo BRL OSOD 44 t ,
IJ,3.71"ossAeru24e 011. moovo I
1,2,4-TriohlaroAm»me BILL 0.500u80 r "
1,1,l.Tdddomc&am HIL 0.500 ugh 1
t,i t•Cd�IaoetAant: BIL 0.500 ugh t +
TriddmO Amc HIL 0.500 u0 1
TIid150rOHYoroOttOLele fFrcoa/l) HIL 0.500 40 I
I2J•7lichkroprwpoe BRL 0300 ugA 1
I,A-TrimaArlb now HIL O,S00 og•'I 1
1,7J-ThmMyllew%m5 HIL 0,500 upA I .
Vinyl 01110 a 13RL D.500 ugh
"4PXylwae BRL IM vjrA 1 .
o•XyRae SRL 0.500 uv! 1
re"VAOhna BRL 10.044 I .
Tow"I methyl eha BAL 0500 44 t "
ikb)iwalwrylcdar BILL 0,500"&A I
of-womldAa BRL 0500%A t
Tat.Bowol r bmt,llkftl HRL 10,0 ugA t
Svro� I.&eattylowobeoveae 85.8 BP110%
SraropoEc'TwlwmwifR tOS D.IN%
Srrresm, 1.OldderoaAeaed4 91,4 80-120%
SYrsYote:011rroeeyTwwmeedA NO 80-120% -
T10601*0vareOer "aetbbe.t01 Id
1*ft epadag'wdt&mpn 7111nom
Aoao.Olel mo a�lao h 5ta stet alrtp�n
dtliDpuipnord endare uwtl toNff'fx8sat
PAMM
7Akla9wrwma7rtpwrr flow
r+Rl w@iw u wwverlraf ekrWaa�w Neai+o fie.
•RrryorolWa 1?rteehoa Limit B1IL•�Berow Aepenbrg Lyall Prpo J of 4
.T,. M. .•A�lam+ r�.:,4w'N.r'+•' J'2•'�!.�!�^,`.M!!Iw'PLJaL1�".. S::rL•Pa i -r .�...;....�.., :;.N.........:n..Mr�f.
__. .___. _ __. ._.._ -�-�e,.e..eo l'6/LID'YJ bV 11 i ai53m F'• CnZiS
FPv:� SP[(:T?7M ANAi.YTiCA[ " IFRI) 8 222(0[; ' J:;?8!ST. ID:;6/Nil. SS10232128 F 4
1 M iA w401y Clmut 34oieelN MAIM On"Ill0ADot
errmr0 Raecirai
6Y 34331 [rows) Uru4k10g Wma 17:-Aug-03 00:00 12•A46-03
SAM860.01
M40ttPi1 �_ R1m8 *ABOWnb Paul lr_A9eiMM. lWmwd Awed &*A An"Rex
ToW Mitib by RPA 266 Swim Methods
S89a BAP. •0003 me 10 PA 200! 19-Ak143 1144.03 301079S kdd
Ahmicum BRL .0320 m24 10
LOAM#* SAL .0040 mgt IO •
✓Barium 00087 .0000 m3N 10 ,
✓ Ilimn BRL .0010 me 10 ,
5v CttdOm 2.T 0250 mgs erA3an7 1s•AuM3 3a01o> rs i
1/6-6oum BttL .0003 m&4 10 EPA 300.4 I7•Au043 711/0193 kylu4
✓CluaNmn BRL 0000 102/1 10
✓C04[,47 BRL .0010 m8A 10
✓Iron 0.0950 0025 RVI I wA2007 15•Au/-03 7010791 RE -
✓Mmuy BRL 0004 we I 9?A 315.2 ' I5-Aug-W 3030747 YP
AJM16.5cp4 4otslum LI6 .0500 me 1 VA 200.7 f5-Au&43 3010791 RE
�i m4pcwmn - 4.20 .0125 me I
✓Ma111u 10.0237 .000.1 WWI 10 8114 2O I7.Au443 703W95 ksiva
30611R1 371 .0230 MMI I VA200.7 15-Ault-03 3010191 RS
✓Nkks4 BRI. .0010 aw 10 EPA=5 iNAW03 3OW195 Igtut
✓tsd BRL own WWI I
1/RRGmony 8RL 0003 w IO
✓841r/i1m1 BAL 0006 owl t0 ,
✓TIrIBum BRL 0000 mgA 10
Zino ML AO10 me .10 ,
CcRun1 CYttmflt#g Rcrsllonn
zy-10D 01ui AOWWty _ its I'm mgll. I OML3208 I2,Au1'03 I3-AU4 3010637 d .
CaCO3 -
✓Chlorw 100 1.00 mgA 1 0,%300A III-Aug-03 13-Acg43 3OW70 Ckc _
✓ Cola 0 0 Color Unit I cM 21208 UI-OkO 12.Agb03 30106#7 CT ;
J Cytrdd4(out BILL .0100 w I 16 U41t-1-A 111-41W N-AUS-03 3010992 jkk
✓
plums 0A50 0.100 MIA I BPA 3004 ill•Auy03 U-Aug43 3010170 Ckh
./.Ford" 524 1.00 W41 I SM2310C 3M1A9143 14,AUN-M 3CM93 NJ
J Nii&u N BRL 0.100"n I SPA 300.0 rhA*03 mmlu 3 X470 CM
72:00 -
✓NRdu u BRL U.3130mdi 1
✓Oda 2 0T.O.N. I C3 or)1 rl-AWO 12•.40" "Am CT
16:00-
1/p11 020 9N Unit I BPA Iml 3010116
J Tdr4I Oiaol+sd Sdhu 100 SAO Tw I 3µL410 C . I4.A0/43 301CAU wh
:1Sd8dea6SO4 •f 19.1 1,00 Mp1 1 BM XU' rMA1g43 13-A443 3010670 00
TuteidBy 0.16 NTU I 6M1U3011AS0.1 13-M543 114403 3010686 Ct
1640
fMi7".*O7'Mort4cwmWwNew4AauAWadt#wW4MOfit w PW,
•Ropw166kDotati9aLirrsl
S&L-,8e1o399gorrkrgLink hle4ofil
il"Ezm F. -,
FROM 31"C-1PJM AWL YIICAL (FRIJ 8 22 ?01i3 'O'28/ i, j0 , S:'0n2128 P S
Senile ldeadflglh!}8 C0IenePmieet 7Y i Calkom DIII&T ale Astived
ST 3051 [atacj I b`Aog`O3 00:00 MAug-03
SA00g6O I
'dum"eemµle lata m uoa:
Aa/ Y1 NMWP 'fOLrf/�OR Dgm*m ' M~Z
,. � fd M}w0' Aoabrd So" Aas[.s plat .
N�
SabweoeefeQ AmN,rele See Repos %by Weigh eh Itl`AVQ ltwftl eNSL
6
i
I .
. 7Air/AitrwygprAioM talld wkAeaea n¢Motuftapbwm ke aero/rge.
4Repw"IeDewc0anUm4 BRt.>O4owRepotedngLodi PegeSoto
...r��YlrwLfv'M�..1'1r•:wM'lA..... . .i .reM1/.w�. • ...�.:i. .. . .�T".:' w` YIY'� :'n ., v..iv iA i• .'.
02':'
°POM SPICTRUM An4LC IU L (FRI) 0 22 2008 1Q:28;ST. t0'28!NG. c5102KIH F 5
Notes and Do finitious
BLL. Below Laporerng Ltmie-A».lyte NOT UMCTM at o:abne the tMortiag Ikrdt .
dry Sample resuoa reposed on a dry welglta basis I
RPD Relative Percent Difi`arenne
3hg�11018D�1ds1 Sasmle fLGSY A known mattia W&W wide oompemhd(r)repeeassutive*(the atgd mtdytes,which is used to
docheretea[IsboespteY pasWmtases.
;, An mare-laboratory split"it which is used to dommeat the precisieah of a meWod in a given aampic matrix.
Model As aliquot ofle emsple spitted with a!mown cos mtastim dtarget ataiyse(a)s Tho spiking oe urs prior to aemple
prepared=and 6alyab. A soatrL%spike is used to documents the bias el a®emod to a giwni emepls maerh,
hlslbadD aflli .An aadyk five matrix[to whwh aU rwgtab are eddied io the same volo r ever ptepprtlprya as used,insamgsie
proehoaiog. The method bLak ehoukt be carried through the complete:temple P+aPmation:ed tial analyprocedure. The method
blank issued ee atocumont chmamilatioa tmuisiag Thom the elelydoal pnsases.
aiditraL�11.(�dj k Tho minimum eoeaenratle4 of a substance that ern be maamued read mpmted with"%
a pee secs dose tbeass lyre moaeasdw fsVater than urn and is aborcmined Acmaatyru of a ample in a given inserts:type
comming the sjwlyte-
� 'foo!sweat toshomMtmion tmttsn les roliabiy aeNeved crhbia apecl6ed llmlao3ptraisior,sad
accoacy during rostina laboratory operuLtg eooAdoaa< To RDL is g st udy S to 10 dmat the MDL. However.it may be
»ombeslly creased within these guidelines to sksplfly data repo ting. For may moon this ROL soallpe t mcent»tion is esteetsd ss
to lowest awatro snadard in the calibration curve. $ample RDLA at bigbty ms six-dep a ade s. ,
$yam Aa tirgenio t onr% d arbieb Is sltn0sr to the target asalyte(s)in deoameel 000nposill"sad bolu viter iu the asalydcai :.
pmcam,but whiob Is am awmmslly Cooed is tavlrose+eeal sampks. These compatmds are spiked into alt btaolrs,standards,and
tunplea prier to ihoelyais. Fastest tarmerim ars esleulaNd for each suhrogata.
I '
7A1a M9amrsNe�n tr sit tslW hsPial ss ew'IterbsrisPptsmtte w Plaararpspe.
�gapontArla Demerion{.tents 13AL Wow Upmsiag Lima p"469(6
;ROM SPECTRUM ANAI'fTI AL (PRI) B 22 2C33 10'29/q, 10:26,'NO, SS 10232128 r
n
M5L Analytical, Inc.
teoron+nwd.fYl+�Nr goes .
ian IFW IIfM1ll.--M4: nM � ��OIt9a9a1a1 r:'
a. w.Kea� c"o�ww aa�w
8p4p,wn 4,ugrne49 cumww Pct
11 41n�fM Oc�nr Mm4od: OwMW 4:0e FYI
4�y�,M40R9W
" a BOU �p767719
' u: N9777M10TIf. PPOrM. ( 97170L lM66 DML/:
7NpfA0g10 !Ya{,Oiopo110; '
PnMyW Dar, Wti9cos ..
Aeterralnation of Asbeatoa vgveturec o+rer OUM ilt 6eno to MOWN Water
Performed by the EFA 400.2 01008d
cor�udtaAtttaSN
MiALV71C4L D�
1/ 1�6l1S1N6 /WD1MAIDelSTDID TW!(5101 51IWYMITt' COWM"" OCNam
FIBE71
a.n
leP�l10 0,064.11 a
e.tv
aa9eFCear —
I .
y ).
M rmr•
I
Zoo'
1�1• ' �`• paaor ta0�OM 4A��'
aMiUNwWlq M���eMN�1��rIMrN�w�1r���Mn�MI�I�aRMn+�aM�P�i
yw.41MM1tlaMM',�N�l+.iM ��Mwl/��I.au�NOM�,wy�,.lpSFs�HNM�
. i��FwW NUUWW"��s �1MnMWN4 gAlYW nMMMIOd/A
.WiM6iMdM' yy Yr MYMi W1YMYi�FIIwMN�ti MDRIMiIY' ![1P '. .
Pv WPkY M
TMS IS THE LAST PAM qP 11AR R£POaT•
', StlLT'��i!N it:,.C'i �r'ACiXS:w�"'..: .... . .. .•
N
_ special Henduetg.IrcN
to �nSb�AT-Ma N teed!& +%
CHAIN OF CUSTODY RECORD
QI(iR�tMA(f401t.IC _ - All TATs wllta to ttatwman amm W,
Aga 244totr wmirwatiml tlnidtd 6 waits.
r � �� l � AHsmgr(esMditpmsd afabrregd�rt
N J Reylai io= � G'
S-+F1 m�laa as
r+ � Ntoict Tr. al � i`•
P eetttta:
site Name: IA Rur.strc - k _
(.aerlml:-�����_ i• .nig _ .
-
FY�t.Cimp' 1 M_V-din-- T.iA. �w•�f�f�' ___._.__-_ .-
N
- ('►B�HlOt ' Z�li1C1 7�HSOa 4¢INnr 3A4LLi '6+AtepWe Acid Caeuuea: Aaalraes: ltatea:
°' nll=ntedaaf w,ta au'-Oraotawau. 9Par=xmtsmatl.
n - O-Od StW Suttica Wap! SUP-Sad K-Silfte A-Ail 3 �-
r S f > � tri ►!Lab Td: Smaptrtd: natt: Tnwr fT` 'S --E . s
a w : :
c
i 1
i
- t st
F-
- Raattsld _ - _ Ogee Time
d � so
i Cliurts+tbawMtaalLWcto(�J _ PM
,� O F-trod-rewgs**4m avid"(a g� i�1 1
Coa&m upon ft=W O ked O AuWmw Q_•C �. _
_ special}l"ing:
. . . C1_5t=dad TAT-7 b 19bm�nnsdays
� .
VAE �' TAT-Dale keeAedZ _ - i
ff, CHAIN OF CUSTODY RECORD - All tATs stirod to hbor4ay apprasal. i
y SI iL11WlIM$bL 166m 24-11 ur woWkwim meded for gusto.
` .- ,111saasplzs ece dlsyraed ol'aAerAda)s - i
I Y1�1iL90106T f af� Wkw edm -iw inswidea i
S, o Repan To: Inraitt Ta: _ Paajnti Wo
� �i• A alr 1�_ �!I ------•I�r A
-
----- Coelia!_ r �AaB slraa:
f1
Lhl Mp.: P.O.No.: r IiQN: -------i '
.rY�CYl l�•YY ).�Y M\ •.Y\'n <�iLA\L b�n.�A�.. 1...A
�� . -.�...-\.g .�.... s- :w• �.. vi ..•.... o .........«...... f,'OUW16Cfi ZQiAg6lYbti: � HWQ: j
^' 7•CflO" 8-Na1150. ••9-=_- 10•
j
<� DA'=OrmbegWater CW-Garkd*-Af WW-Wasgesra[er j
SL-
SO-So
4 Oil SW=Staiaee Woe: il Sludge A�Air
xl= X2a y •� `
a _ = xa=
n `.a t_.a'..as f:m(�goeorige ( � i a �_ � � 2 1 D � �► Q I
O` N ` I
Lab 1d_ samot Id: Dare:
r
q
it R A }f Y gr i Y ll' III
I r t
I
I
� 1
-- Eecaivd Dote Tum
pr-
H Fa.rcwlu w1Kn asailabk to -
4`F OE-egaiim-sidts when a•oila6kfo -
Coadkion uom ROM":
O Ambien
. 1
11 AvDri%w•Ar,e .i ,Mu> chuimm MOM•413-789-9018•Fax 413--?89-40%•a�vw:tprctram-v,�lriulnm -
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
g� 120 WASHINGTON STREET, 4TH FLOOR
�o SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location 12 Buena Vista Avenue
Owner Nhan Kien Hoang
Address 9 Marion Road, Salem, MA.
This permit is granted in conformity with the statutes and ordinances relating to
well permits.
Well construction permits are non-transferable.
This permit shall be on site at all times that work is taking place. Permit shall
expire one (1) year from the date of issuance unless revoked from cause.
This permit does not constitute a Water Supply Certificate.
Permit # 2-03
Date issued 7/23/03
(Artesian well) (Avellino WellX& M
�� 85)
Health Agent
&
N �bo d3�
IMPORTANT MESSAGE
FOR
M.
DATE �` � `3 TIMEY�
M L
OF
PHONE ��� 9 :2 7- �D� Xc3a7L��
AREA CO NUMBER EXTENSION
O FAX
0 MOBILE
AREA CODE NUMBER TIME TO CALL
' TELEPHONED L<PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
G'
SIGNED( FOA
VrOPS. MOAR IN U00