42 HILLSIDE AVE �� �/,C(S%� Aar (weCcs��
I
ocyctra'o
UPC 10330
No, 153L st ec000t
HASTINGS, MN
it
'_13 �tl,�5�
l � i 9
P 1 2 1996 � � � AUG 2 0 1996
CU r "_RL;,I.,_ TY 07 4.L d
CITY OF SALEM BOARD OF HEALTH '1-
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Fax:(508)740-9705
Permit# Date
Application for Well and Pump Permit
A permit is requested to: drill a well-X_; install a pump X _; other
LOCATION: 1 -4 0/ - Lot#
Owners oE_ F (-, Address yZ�CZS E �UF_ Tel.
Well Contractor V1 EZo 6dF-ZL�c? Add. 5'%6'E0, Tel.352
Pump Contractorco//-m//✓t'7e,.✓ /vl,) Add.639Tel. d�9!//
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Wells (To be completed at time of pump test.)
Type of well IQDZAeo',QWVJ . J) Use 1
— �,elG67lDN i
Well Diameter 67- Size of casing (.d
Depth to bedrock A3' Depth of casing into bedrock
Was it seal tested ? yes (><) no ( ) Date of testing 9--a-%
Depth of well 016 - Well ended in what material ? RADAff )�Wpik, ��C t •6�HQj�
Depth to water d1a Pelivers c,2?) Gallons per minute.
Drawdown 71l(T' feet after g hours at o 4 Gallons per minute.
(Please sketch map of well location with tie n re
lines on rev e si e of this form.)
Completion date:C Well contractor signatu
Pumps (To be completed before installation.)
Name and size of pump: Type
Water pump delivers: GPM. Size of tank
Pipe material used in well: cast iron( ) galvinized ( ) plastic( )
Circle one : Well pit or Pitless adaptor.
Was sleeve used to protect pipe? yes ( ) no ( .). Well seal type:
Date: Pump installer signature: Reg.#
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Plumbing Inspector Wiring Inspector Board of Health
SO
Department of Environmental Management/Division of
Water Resources
� d WELL COMPLETION REPORTe, i.
WELL LOCATION GE0l3ftAPHIC DESCRIPTION
Address ,,..�.��/!• �6 r, N S E l°=/ of
1
- / (clmisl
City/Town 5'//!f"/N /�� y/1(T /'iQr o;_
Well owner / (ro,d]L_r tFl/✓�6'l�
Address M,fiN. S E of
-
AW feircl
Board of Health permit obtained: yes
no ❑ intersect. w/ rre.el WAff1 A
WELL USE WELL DATA
Domestic ®_�Public❑ Industrial p Total well depth7V'5- ft.
Monitoring❑ Other Depth to bedrock ft.
P.� ��/ Waley-bearing tocklunconsolidaled material:
Method drilled
Uescription&?4�`�
Date drifled
Water-bearing zones:
CASING ' - 1) From 4& 'C To VM
TypeC%�f"�! /,'
21 from rf/f To Citi
Lenglh_e,C2ft. Dia(I.D.) e-'—in. 31 From >eo To 7a5-,
Length into bedrock ' ft.
- Gravel pack well: dia.-
Protective well seal: -
Screen: dia.
Grout.[] Other„Sf/es�' Slotlength from_.to—.
STATIC WATER LEVEL)all wells)
Static water level below land surface_�___.ft. Date
WELL TEST(production wells) -
Drawdown-2:MIt. altar pumping__lir.—min.ate_k5 gpm
How measuredAl.Je,----Recovery O ft. after-/—hr.l min.
0
LOG of FORMATIONS COMMENTS
Matedeb Frem I To
(1 ��
- � Driller �� c���sc
�! � «
e5� 300- FirmZ1,.�.,�,"AA�A,�,yll.de&� -
.Co Address &We 4.�,--f
City/Town,
Supe iry sing Drilllbr eg.p
Sig rv(a/n "!stoma we/I Ci01ar
Plans Pnnr lily ' --•-"��
So D OF HEALTH COPY