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17 INTERVALE ROAD CsvnC' 12/09/2013 11: 21 9782814869 WINDRIVER PAGE 05/11 Commonwealth of Massachusetts Form 4--system Pumping Recard5aeh Massachusetts System Pumping Record System Owner system Location R.B. Strong Excavating&Sewerage Contracto Job Site 1.R Bond St. 17 Intervale Road 3loucestet, PTA; 01930 Salem, MA, 01970 (978)-283-0060 x 1,979)-283-0080 x R.B. StrongExcavating&"na�,rQr--age Contract r Type: Emergent Routine Cesspool: No Yes Septic Tank: No F-;7 Yes Date of Pumping: 1924. 1-3Quantity Pumped. pto Q, Gallons System Pumped 8y:. Wind River Environmental,LLC Permit#. Contents Transferred to: Contents Disposed at: Date: v Pumper Signature: Condition of System/Other Comments I laver! ill �. aG S Porter -- -- Bradford, Ma 01 e35 - (878) 374.2382 ® Vineao,acycmlpaF+cr Dep Approved Form-12/07/95 1Bureau of Resource Protection V�i WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: 17 1 JINTERVALEST Please specify well type: Building Lot#: Assessor's Map#: Domestic Assessor's Lot#: ZIP Code: Number Of Wells: 101970 Cityfiown: Well Location SALEM In public right-of-way: 9Fg'y� GPS North: West: !7e ry0 ® 42.49035 70.89943 Subdivision/Property/Description:. 114911 f� q(Fal Mailing Address: y (T, F click here if same as well location address Property Owner: ry Street Number: Street Name: JACK PATTERSOW-7 117 JINTERVALEST City/Town: State: Engineering Firm: ISALEM MASSACHUSETTS ZIP Code: 01970 Board of health permit obtained: (07 Yes C Not Required Permit Number: Date Issued: 00 3/25/2011 Massachusetts Department of Environmental Protection + Bureau of Resource Protection—Well Driller Program Well Completion Reports(Generall Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Air Hammer Air Hammer 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 F7 G Loss :GAddition WELL LOG BEDROCK LI HOLOGY From Drop in Extra fast or slow Loss or addition of Visible Extra To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips 15 115 Granite r Yes O Fast G Slow r Loss r Addition �Ye Yes 115 215 Granite I r Yes r Fast �' Slow Loss f Addition r Yes r Yes 215 225 Shale r Yes �' Fast ('i Slow � Loss �'Addition r Yes r Yes ADDITIONAL WELL INFORMATION Developed I C Yes ( ' No ' Disinfected r- Yes G No Total Well Depth 1225 Depth to Bedrock 115 Fracture Surface Seal Type iNone Enhancement f 'Yes No CASING r Is Casing above ground?, From ^ To Type Thickness Diameter Driveshoe 25 Steel 17# © r Yes SCREEN No Screen From To Type Slot Size Diameter --Choose Screen Type--- WATER-BEARING ZONES --WATER-BEARINGZONES ❑DRY WELL From To Yield (gpm) 218 220 30 PERMANENT PUMP OF AVAILABLE) Pump Description ---Choose Pump Horsepower ---Choose Horsepower-- Description--- - Pump Intake Depth (ft) Nominal Pump Capacity(gpm) Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ANNULAR SEAL!FILTER PACK From To Material l Weight Material Weight Water Batches Method Of Placement (gal) OChoose Material Choose Material tI I I --Choose One WELL TEST DATA Time Pumping Time To Date Method Yield (gpm) Pumped Level (ft Recover Recovery (ft (HH:MM) BGS) (HH:MM) BGS) 3/29/2011 Air Blow With Drill Stem 30 04:00 225 00:05 222 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate (gpm) 3/29/2011 3 30 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 i knowledge. Driller JAMES BRAZEAU Registration# 173 Monitoring[M] Supervising Drill Firm PINE SULUVAN DRILLI Rig Permit# 0016 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. � k Kimberley Driscoll Mayor WELL CONSTRUCTION PERMIT Location: 31 Intervale Road Owner: Jack Peterson Address: 31 Intervale Road, Salem, MA 01970 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#: 001-11 Date Issued: 3/22/2011 (Potable Well) (TED Inc. — Reg. #560) HEALTH AGENT ee WELL dH wells-Filters Pumps 1ATER RhCONNEMON,INC. Water Well Design&Project Management Stain Removal Services Design John Larsen ` Well Water Connection,Inc. E`E PO Box 158'Tewksbury,MA 01876 - ••w �1 Tel:978-640-6900'Cell:978-804-5146 - Fax:978-640-6901 '998-840- " Email:JLarsen@WellWaterConnection.com '"jpFypOa"e www.WellWaterConnection.COM Rpr 10 0e 03: 14p Joanne Scott Salem HUH till" r45 Uatd P. CITY OF SALEM, MASSACHUSETTS BOARD.OF HEALTH on 120 WASHINGTON STREET. ATN FLOOR SALEM. MA 01970 TEL. 97874 1-1 800 FAX 978-745.0343 KIMBERLEY UR15COLL JSCOTT@SALEM.COM MAYOR JOANNE SCOTT HEALTH AGENT Well Construction Permit Ippilcation Date:y / 0 Fee: $160. Check payable to the City of Salem (no cash) Location: l ed Salem, MA. 01970 Owner: Q Address, '� 1 2n ol, Cd Tela�L-SU2- 1 �l Type of well Cl�t Gf� Well use: 7::r--r Well Contractor. i�,kzzvlG, r\\oS Pump Contractor: Q a�&-�o-ayy Address: P0R� IS& >,� Ao19 Address: /a 1 m��Sl 1�m N" q o e l? 6 a (ggco Phone: pro Phone: �o�R.l w w � t 8 `4 �7� 6 Y Reg. #: /?3 W Have abutters been notified? (y)_ How? in rhe 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 Dation, which represent a potential source of contarninetirnl. `` There is no fee for monitoring wells but a permit is required for installation. B.O.H.use only. Check#:q, check date: V d�/I) Permit J io Wep const permit appl ruedltrz5102 gY TG. A /� 3 Supmr -SHEET No. LOF.4L_ C4KD 87 DATE " '� y JOB ND ` A41�art. tar'' iw too fft�r CIA_. '� .• ,. .�, � �� � '��ter' M� ;. r c :r s fj�/ . T' re ell LEGEND: -;Street Une Registry of. Deeds. Prope)ky Una emook ���_ .Page •9G Re}otn(ng Wolf .... .. .. 0 � a • ..•—; RIpar aYo �� cel 70 Fretici �ihe ;An C.�f1Rad es In `:' «�r: wrw .► 6 :i. . . tYNH; °engPneers tom: . i. Meti �.. P.D:. Bwt 1303 // k �;` �5 imi»' _. l�fciblehetld, Ma: Of9A5 Y7h NNOL ligluy f10 �� ' � �"��• bG . in d ar. ab =' „�T.•�Gd t;r+��/4oY'�OG2�etiZn/.a�+l/12v!1i.' mdnrr to ifa mnht� 'd' ", ::..•. ..� ;� fie pmpmbc Or dbni H a. a ;' • „ .. r: , Muemd Afoa m : .i:.< CmnmumtY N0. ., i�:.. : '';... ; ,•' }aga.� . oaf[ELL MAULER © � CONNECTION, INC. Water Well Design & Project Management April 17, 2007 Board of Health City of Salem 120 Washington Street,4th floor Salem, MA 01970 RE: Application for Well Permit -Peterson Residence, 31 Intervale Road Dear Sir/Madam: Enclosed please find our permit application plot plan and required fee for the above referenced location. If our application meets with your approval,please fax a copy of the permit to my attention at 978-640-6901. Please do not hesitate to contact me you need additional information. Thank you for your assistance in this matter. 'E c; Sin erely,OJ MAR 1 3 » I per cy Cop i Office Manager Enclosures PO Box 158 Tewksbury,MA 01876 1§ Phone(978)640-6900 Fax(978)640-6901 ® www.wellwaterconnection.com L7 s, Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System Owner System Location Kirk Agnes K. Primary home 117Intervale Road 17 Intervale Road Salem, MA, 01970 Salem, MA, 01970 (970)-744-1874 x (9'78)-744-1874 r. Kirk Agnes K. Type: Emergent Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: (�i_�Z_6f Quantity Pumped: 4,AX Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: r �P SALE COF Contents Disposed Disposed at: Gen Salem, MA. Date: 9-1/7*& / ' Pumper Signature: II Condition of System/Other Comments 00 f ® Printed on recycled pope' Dep Approved Form- 12/07/95 ,r 3..•.t Commonwealth of Massachusetts Form 4-- System Pumping Record Massachusetts System Pumping Record System Owner System Location xirk Agnes K. Primetry Home 17 Intervaie Road 17 Intervale Road Salem, MA, u1970 $alenl, MA, u1970 (v7d)-744-1874 x (976)-744-16'74 x Kirk Agnes K. Type: Emergent Routine � Cesspool: No Yes Septic Tank: No YesF Date of Pumping: 66 6 quantity Pumped: DOa Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Ipswich Water Treatment Plant Ipswich, MA 01938 II Date: Pumper Signature: Condition of System/Other Comments f Dep Approved Form- 12/07/95 i 0� �12009 CITE OFVor CH g0�� ri Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System O Nuerecl, beck .{urd: �Y:RGFELCE (5K) System Location 08 Kirk Agnes K. Pcimrary Home 17 Intervale Road 17 Intervale Road Salem, MA, 01970 Salem, RA, 01970 (978)-744-1874 x (978)-744-id74 x Type: Emergent Routine Cesspool: No a/ Yes Septic Tank: No Yes Date of Pumping:—9- a97J-O-7 Quantity Pumped: Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Salem, MA. Date: Pumper Signature: C)Cwi� Condition of System/Other Comments Id/ {07' Dep Approved Form-12/07/95 Farm 4 -- System Pumping Record Comnaavea"of Massachusetss Massachusetts System Pumnim Record System Owner System Location Kr c, V Q:imr7 Homo .7Ir+. wale Road 1.7 nter✓a7.t Road �a ar, MA, 01970 Salam, MA, 01970 -18''4 C ;978) - 744 -1874 x rr; .a. Type: Emergemy Routine Cesspool: Mo Yes Septic took: w Yes �. Date of Pumping: Q Quantity Pumped: Gallons System Pumped By: Wnd Rimer Enwwwental LLC Permit#: Contents transferred to: j Contents Disposed at: Date: 3 Q J Pamper Signature: Condition of System/other Comments 01 SEP 15,10095 GUiY':QF SAfiMM BB)AR9-OF,-HEM TH Dep Approved Form - 12/07/95 Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System Owner - System Location Kit.k Actnnr X. Pr tmary Home I / 111t3rV91.e Rcx,)d It Int,�rvclle Road - Sr�lveu, FSP„ i�!«'tU 5a1^.gym, NA, 019'/0 0181 144 1874 r � 14t 144- tE74 x Type: Emergen Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: Quantity Pumped: 6366) Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: i Date: Pumper Signature: Condition of System/Other Comments REOEIVED DEC - 4 2006 CITY OF SALEM BOARD OF HEALTH Dep Approved Form-12/07/95 Form 4 -- Sy stem Pumping Record TT�� Commonwealth of Massachumiss ��q R 1� ED Massachusetts Ly L'f I'\I'�'1�'0 System Pumaina Record MAY 2 1 2001 CITY OF SALEM HEALTH DEPT. System Owner System Location John Kirk John 17 Intervale Road 17 Intervale Road , Salem, KA 01970 Salem, MA 01970 Type: Emergency Routine Cesspool: w Yes Septic tank: w QYes Date of Pumping: �S-�r,�Q Ir Quantity Pumped: le�—dQ6ullons System Pumped By: Wind kiwn•Enve wnmenta/, LLC permit#: Contents transferred to: _ Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 ' CURRIER FORM 4-SYSTEM PUMPING RECORD SEPTIC & DRAI ERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978) 774-2772 �IIIIUUUUIIII;��444d___4444 OCT 4 -- 1999 COMM EALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPT. 0. 'vet MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: G� DATE OF PUMPING: �. > ,F_i:j QUANTITY PUMPED: / <d_Z GALLONS CESSPOOL: NO E;3 YES SEPTIC TANK: NO YES �• SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: � S% DATE: / INSPECTOR:L �� �/ 107 Forest St. N ' Mldmeton,MA 01948 � ��GpPNp, FORM 4- SYSTEM PUMPING RECORD 65 000 Commonwealth of Massachusetts !AN! 1 i' 1098 Massachusetts sr=OHLEM System Pumping Record ystem wmer System Location S cAe vv-\ Date of Pumping: ���� �/ Quantity Pumped: /bLgallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes System Pumped by: 4L/ r' ,r CC 1542}1C License #: Contents transferred to: Date (�r ��/C�2 Inspector C,•Gj ..... JI. ..arc....,. (5081' 774-2772 01949 -`� �V000 FOR114 4_ sE SYSTF.III PUI%7PLNG RECORD' Co►nmonwealth of M �l S assachusetts ai V- Massachusetts L 110q 1 1997 l jt cos y Stern nes ystern ocatton ate of Pumping; 3spool: No Quantity Pumped: Yes gallons Septic Tank: No C em Pumped by: Yes �— feats transfers ed to: C License Inspector • THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY•