295 DERBY STREET D
Massachusetts Department of Environmental Protection 40i4
`.� Bureau of Resource Protection
`h Well Completion Reports
1
Well Driller
Please specify work performed: Address at well location:
Decommissioned Street Number: Street Name:
M.PEAVE® 295 DERBY
Please specify well type: Building Lot#: Assessor's Map#:
Monitoring NOV C,i 0 2013
U o 1 Assessor's Lot#: ZIP Code:
Number Of Wells: 01'y OF= .}LEM
00AHD GF HEALTH
City/Town:
Well Location SALEM
In public right-of-way: GPS (GPS for the deepest well)
G Yes CO) No North: West:
42.31176 70.53518
SubdivisionlProperty/Description:
Mailing Address:
click here if same as well location addres
Property Owner: Street Number: Street Name:
2 MERCHANT
City(fown: State:
Engineering Firm: SHARON MASSACHUSETTS
ENVIROTRAC ZIP Code:
02067
Board of health permit obtained:
G Yes fi Not Required
Permit Number: Date Issued:
0
Y
Massachusetts Department of Environmental Protection
�i Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Decommission)
Well Driller - Decommission Form
WELL INFORMATION
Date Decommissioned 1111412013
Depth of Decommissioned Well 20
ADDITIONAL INFORMATION(IF AVAILABLE)
Original WCR#for
Decommissioned Well Well ended in formation type G Overburden G Bedrock
Was a new well drilled? ❑Ye WCR#for New Well
DEP 21E Site# DEP Groundwater Discharge#
CASING
Casing Type lPolyvinyl Chloride Casing Diameter. 2
Was casing ripped or
Was Casing left in place? O Yes F) No perforated? r Yes r No
Were obstructions left
in the well? G Yes r No If yes,what type? --Choose Description--
Surface Seal Type O�
DECOMMISSIONING MATERIAL
Water
From To Material l Weight Material Weight (gal) Batches M
0 1 Native Material ---Choose Material---
1 20 lBentonite Grout ---Choose Material--- G
WATER LEVEL
Date Measured Static Depth BGS (ft) Flowing Rate(gpm)
11/4/2013 1 15
COMMENTS
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
. �. Well Completion Reports(Decommission)
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision, according to the applicable rules and regulations,and this report is complete a
knowledge.
Driller DARWIN NEWTON Registration# 606 Monitoring[M] Supervising Driller
TECHNICAL
DRILLING Date Job Complete
Firm SERVICES, INC. Rig Permit# 70
NOTE:Well Completion Reports must be fled by the registered well driller within 30 days of well completion.