72 FLINT STREET Massachusetts Department of Environmental Protection
LO-1 Bureau of Resource Protection
WELL DRILLER
Please specify work performed: Address at well location:
'New Well —� Street Number: Street Name:
72 (FLINT STREET
Please specify well p� RECEIVED Building Lr ot#: Assessor's Map#:
Monitoring I fI
AUG 1 C �p12 Assessor's�Lot# F Code. ��
Number Of Wells: U U
11 CITY OF SALEM
BOARD OF HEALTH Cityrrown:
Well Location SALEM
In public right-of-way: GPS (GPS for the deepest well)
r Yes G No North: West:
X42.52240 70.90656
Subdivision/Property/Description:
Mailing Address:
Er–click here if same as well location address
Property Owner: Street Number: Street Name:
I mil-EJNIAL biiA
City/Town: State:
Engineering Firm: IPEABODY MASSACHUSETTS
WESTONANDSAMPSON ZIP Code:
01960
Board of health permit obtained:
QYes C Not Required
Permit Number: Date Issued:
j 8/2/2012
Massachusetts Department of Environmental Protection
—' Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Monitoring)
Well Driller - Monitoring Form
DRILLING METHOD
Overburden [Auger Bedrock -Ch( oose Bedrock--I
WELL LOG OVERBURDEN LITHOLOGY
From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of
(ft) drill stem drill rate fluid
Urban Flt Brown Elr Ye (: Fast f' Slow (` Loss G Addition
® Fl-27 Silty Sand Light Grey rYe Fast r Slow ! Loss r Addilion
PERMIT INFORMATION
DEP 21 E RTN# DEP Groundwater Discharge#
0
ADDITIONAL WELL INFORMATION
Developed r Yes C• Wl Are these wells nested? C Yes f No
Surface Seal Type jCement I Area of group(sq.ft) 11130
Total Well Depth 12 Depth to Bedrock
CASING IF Is Casing above ground?, From: To:
From To Type Thickness Diameter
2� IPolyvinyl Chloride !Schedule40
SCREEN I r No Screen
From To Type Slot Size Diameter
2� 12 Blotted PVC 0.010 2�
WATER-BEARING ZONES
From To Yield
(gpm)
7-7 0 1
ANNULAR SEAL/FILTER PACK
From To Material t Weight Material 2 Weight Water Betche Method Of Placement
(gal)
CemeniBentonite Grout ---Choose Material-- Gravity
2� Bentonite ChipslPellets ---Choose Material--- Gravity
12 Santl ---Choose Material--- Gravity
WATER LEVEL
Date Measured Static Depth BGS (ft) Flowing Rate (gpm)
8/10/2012 —� ��
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
1.., Well Completion Reports(Monitoring)
COMMENTS
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 TIMOTHYFLORES Registration# ;6&1 Monitoring[M] [-M� Supervising On
Firm SOIL EXPLORATION C Rig Permit# 1267 Date Job Com
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
Massachusetts Department of Environmental Protection
�— Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Addendum)
WELL DRILLER - ADDENDUM FORM
WELL COMPLETION ADDENDUM FORM MONITORING WELLS
Well ID Well Depth Screen Screen GPS Coordinates(WGS 1984)Degree Decimals
Interval FROM Interval TO
2 12 2 12 North: 42.52261 West: 70.90639
3 12 2 12 North: 42.52286 West: 70.90616
4 12 2 12 North: 42.52291 West: 70.90586
5 12 2 12 North: 42.52304 West: 70.90558
6 12 2 12 North: 42.52276 West: 70.90518
7 12 2 12 North: 42.52234 West: 70.90534
8 12 2 12 North: 42.52193 West: 70.90581
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.