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234 HIGHLAND AVENUE ELL i 234 Highland Avenue na ® No. 153L HASTINGS, MN LOS ANGELES-CHICAGO-LOGAN,OH MCGREGOR,TX-LOCUST GROVE,GA U.S.A. Massachusetts Department of Environmental Management 139742 Office of Water Resources TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE 0 LONGITUDE _ 'DATUM Address at Well Location: —2 3Y- /V/6-,*LpNJ #y&­Property Owner/Client: 2 -yz>� CvA�.t'-�/45"( Subdivision Name: --r7-tTLn7 C%92 w&S tf Mailing Address: 6-WI-04-113 City/Town: r Cityrrown: `ems J Assessors Map Assessors Loot#: NOTE: Assessors Map and Lot# mandatory if no tie,'N ddtdss available Board of Health permit obtained: Yes Mll Not Required ❑ Permit Number D Iss d 2:WORK PERFORMED ='„, , ``�� 3°PIOPOSEp:(7SE ;�; 4:DRILLING';METHOD )" EY New Well ❑ Abandon ❑ Domestic ❑ Irrigation JEIble ❑tAuger ElDeepen ElRecondition Monitoring ElMunicipal Air Harprner `® Direct Push EDReplace ElOther Industrial E3 Other!'�w'IS N' ❑ Mud Y Sot .�. "❑ Other 5.'WELL1LOG IPM Water Unconsolidated Consolidated .'6 SITE-SKETCH (Vse'permsnegtlandm rksswith diss r;� Y Bearing _ er Rock Type From (N) To (ft) Zones crip ! P-1 1MDescription 0. � ao Lq-0 7 soa 6l< i1f a 40 3 r 7.`:WELL"CONSTRUCTION. ry-' _, _ " 3�"�� 8.`CASING�-r.��'"�'r� .."� .,*�c � � �3 � ��,� s�x � - fi:�:� u s�r x=,� Total Depth Drilled O From (ft) To (ft) Casing Type,and Material Size I.D. (in) Well Seal Type Date Co late /O / I{D l lJYe�d- We5d2o rr11 tv ,m . 9.'S CREEN 3'a M w'� x F krcs��y��a ':""�r�`-`Y'u .ac'Frasi�`f.x '�Xx'�,d5k .rw5„-,_�`1.0 r� 'i.'rkr4�m ra�*F st"k•r;A i _ �'� �.'.: t�'•*-�e ,', From (ft) To (ft) Slot Size Screen:Type and Material Screen Diameter 10:FILTER PACK7GROUTIiABAND0 MENT.MATERIAL x «z l f x a , * ,;;. rw 11 ADDITIONAL WELL INFORMATION -,r,li * w P F actureed? Yes ❑ No From (ft) To (ft) Matenal Descriptwn' Pur ose P Enhancement? ❑ Yes ❑ No Method A r Gr—j � fix* N� Disinfected? 104es ❑ No 12:WELL'jTEST;DATA(ALI SECTIONS MANDATARY FOR PRODUCTION WELCS)E5 13;STATIGYI/ATER LEVgV-(ALL WELLS),V YieldTime Pumped Drawdown to Time to Recover Recovery to Depth Below Date Method (GPM) hrs''& min) (Ft. BGS) (hrs&min) (Ft. BGS) Date Measured Ground Surface (FT) a r 30 t-a; g t� 10V : ':90 a e 4 ,-2� 14:P.ERMANENTs'Pl1MP.(IFAVAlLABLE)¢ g V 4� , M 15.NAMEIADDRES$AF,PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) jA 16 COMMENTS 17rtWELL DRILLER S STATEMENTS y : This well was drilled, altered an bandoned under my supervision, according to applicable 4, rules and regulations, and t ' i complete correct to the best of my knowledge. e Driller: /?7 Kc/ i� Supervising pervising Driller ' nature: Registration #:L 15, 15 1 Z I 4`3 —7-71.vet(�C AJ L-&L L- C',O `� Firm: _ te:_[ � :c-� Rig Permit#: NOTE: Well Completion Reports must be filed by the o the registened well driller within 30 days of well completion. � Pigg,go FEB 2 2 2006 CITY OF SALEM BOARD OF HEALTH Massachusetts Department of Environmental Management '1,t�\ Office of Water Resources V 139742 TYPE OR PRINT ONLY _'fir Well Completion Report 1. WELL LOCATION GPS`(OPTIONAL) ;LATlT,UDE LONGITUDE DATUM Address at Well Location:.-3_T,y7 r fc l;Gac*r Al 7 , Property Owner/Client: "s rZ f[>nl fT _ / Subdivision Name: �� r lZ< + " a Mail ni g Address: �?y � �= ti ✓*$ Vi City/Town: SAIL ern :L++ t t.���CrfylFoV✓{ .-mss � rr�J �"c -':� � p. Assessors Map Assessors Lof Assessors Map and Lot # mandatory if no,street address available Board of Health permit obtained: Yes 4e,-, Not Regwred.Cj'_ Permit Number Date,lssued 2 WORK PERFORMED , .' 3:PROPOSED USE �:,; 3 r 4r DRILLING METHOD + IV New Well ❑ Abandon ❑-Domestic ' " O krigatiori ❑ ble � ❑;Auger El ❑ Recondition ❑. M1 onitor g ,�,❑ Municipal/ Air Hammer O`'Direct Push El Replace E] Other And stnal F-1Otherl'r,V wW; -r- ❑ Mud;Rota`` C7 Other 5 WELL LOG C';AW Water Unco`n§olidated, Consolidated 6. SITE SKETCH m ` (u rn -0 e'�a emra�aminkswrmaismnces) Bearing RockTY'P•e ; ZoDescnptibn•' From (ft) To (ft) - nWLruh r? 9Vt p dtJ E;t. �•� � .: �`riet#3 4 1. �-,f=s-vi::.-•eR 3 �� ✓€ i ,rqqo r. .,� ,-✓..� „ �£ 'WsFD � f E�F�iISl.�r, col ,y • ... PYA=C.K �-F Jt '... q. f. t •4 i E' A F r -'.' t V 74- h i c 7.WELL CONSTRUCTION, - ,!j, 8f CASW,G' '; t:;x F Y°tt +l) u ¢yt !`• i rrr s r y t Total Depth Drilled r J = om;(fi): To (ft)` `„`. �Casrg Tyrie nd Material: '1i Size (PD. (in) Well Seal Type Date Complete � 3•f71 l r'v;;�'' << ,- , 1” 2 9. SCREEN= From (ft) To (ft) Slot Size Screen-Type and Material Screen Diameter 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL,; „ ",.) : ._ 1T.ADDITIONAL WELL INFORMATION Ra .,� � Developed? Yes ❑ No From (ft) To (ft) Maferrah Description Purpose Fracture Enhancement? ❑ Yes El No Method 01r G, Disinfected? E�Yes ❑ No 12:WELL TEST DATA (ALL SECTIONS MANDATORYe FOR PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield + Time Pumped Drawdownrto Time to Recover Recovery to Depth Below Date Method (GPM) a'(hrs & min) (FV4B'bS) %`°(tirs& min) (Ft. BGS) - ;' pate Measured Ground Surface (FT) 14.'PERMANENT PUMP(IF AVAILABLE) a ` . - e; 15.NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description ` Horsepower Pump Intake Depth ft Nominal Pump Capacity (gPm ) 16.'COMMENTS 3 $i �. N �ar'4 -1'F`-. _ 17.'WELLDRILLER'S STATEMENT„-_ ' "" This well was drilled,-eltere , an abandoned under my supervision, according to applicable ;rules and regulations, and t is r i complete and correct to the best of my knowledge-,*`V07* Driller . C. E I fN 1 Supervising Driller ignature: Registration #:I I� I FSI- 7 Firm: t- �C n1 Ger-�� c.-'•o . ��t c . ..pate: -•' 7 '"v Rig Permit If: NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF:HEALTH-COPY , ���F `♦ t� 3g3 ',_.fist § "`.,T7, CITY CF SALEM MA$SACHUSETT��t BOARD OF HEALTH i ax'z war t €4� d � 5120 WASHINGTON STREET,4TH.FLOOR """`'i `^' 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: 234 Highland Avenue Owner: Triton Wasa Address: 581 Main Street, Wilmington, 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#: 009-05 Date Issued: 12/14/05 (Monitoring Wells) (TED Inc. — Reg: #560) � HEALTH AGENT CITY OF SALEMv MASSACHUSETTS BOARD OF HEALTH s r a 120 WASHINGTON STREET, 4TH FLOOR • SALEM, MA 01970 TEL. 978-741-1800 -� - FAX 978-745-0343 ll STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, R5, CHO v Il II MAYOR HEALTH AGENT `*J NOV 17 CITY OF SALEM BOARD OF HEALTH Well Construction Permit Application Date: Nd vil /d Fee: $100. Check payable to the City of Salem (no cash) Location: ,-�34 Salem, MA. 01970 Owner: TQ I-rar.J W4S A Address SF I moon � - Tel.4 -b - 3100 WIIV-14,C,I-- I ,✓} Type of well: —)1 l U-C O Well use: C g 2 W t)S H Well Contractor: ©GpCN weu's Pump Contractor: S19 rte Address: i•-, CHT rwr'WOoo � o Address: Phone: ) �l��V✓t,1 ✓h rA o t g'7 b q ?�-�f 53 - lj Phone: 8 ?� l7 Reg. #: f I Have abutters been notified?------(y----- How--?----Vi---e—t-t--i---b---A----m---1—m-, ------- ------ In -- ------ the space provided below(or on back)show the location of the proposed well in relation to existing or proposed above or below ground structures. A description of visible prior and current land use within (200) feet of the proposed well location, which represent a potential source of contamination. 0 ��L G�PpOF 1-I Lr� n0 01Je- g0 There is no fee for monitoring wells but a permit is required for installation. B.O.H. use only. Check#: / 8�116� Check date: Permit* Well const permit appl revised 71/25/02 •