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RETURNED YOUR CALL WILL FAX TO YOU
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OIVERSAL4SOD5 MAD IN U.S.A.
NOTES .----
IMPORTANT MESSAGE
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AREA CODE NUMBER EXTENSION
O FAX
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AREA CODE NUMBER TIME TO CALL
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO m
HEALTH AGENT 120 Washington Street 4 floor '
Tel:(978)741-1800
Fax: (978)745 0343
COKVIONWEALTH OF MASSACHUSETTS
CITY OF SALEM
WELL DRILLING/PUMP TESTING PERMIT
Location: 27 Intervale Road
Owner: George Fallon
Address 208 Derby Street, Salem, MA
This license is granted in confc..Amity with the Statutes
and ordinances relating to Well �06rmits..
Permit # : 2-01.
Date : 07/19/20101
4EJAITH AGENT
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BOARD OFHEALTH
120 WASHINGTON STREET, 4TH. FLOOR �yV IS
t SALEM, MA 01970
y �_ !
TEL. 976-741-1800
FAX 978-745-0343'
STANLEY USO VICZ, JR. JOANNE SCOTT, MPH, R5, CHO -
- MAYOR - HEALTH AGENT
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970
120 Washington Street 4h floor
JOANNE SCOTT, MPH, RS, CHO Tel: (978)741-1800
HEALTH AGENT Fax: (978)745 0343
Well Water Supply Certificate Application
The issuance of a Water Supply Certificate by the Board of Health shall
certify that the private well may be used as a drinking water supply. A Water
Supply Certificate must be issued for the use of a private well prior to the
issuance of an occupancy permit for an existing structure or prior to the issuan(:F:
of a building permit for new construction which is to be served by the well.
The following must be submitted to the Board of Health to obtain a Water Supply
Certificate :
*copy of the Well Construction Permit
*copy of the Water Well Completion Report as required by the DEM
Office of Water Resources (313 CMR 3.00)
*copy of the Pumping Test Report
*copy of the Water Quality Report
------------------------------------------------------------------------------------------------------------
Location of well: 2-7 XTERV&E zZP-,9D Salem, MA.
Owner of property: 90dEk'7- #WMEL Tel. T7?-795--M0—
Owner's address: 27 /AIrf.<V/�(E �76 fAC4 M6 0/q-70
Date:
------------------------------------------------------------------------------------------------------------
B.O.H. use only Permit #
I
0027 INTERVAEE'ROAD ' ` r= ' 119=2001
{ GIs# split ' COMM .AALTH OF MASSACHUSETTS
i BtocC CITY OF SALEM
iLot. 00;t, �I
�Permrt' B ilding
Ca[eg�ory: 1 Now^SLngla�famil: BUILDING PERMIT
Percml t# , le• 119=200
Project# _ JS•2002 0144
ESL iJs[i' $76,000.00" -<I
? ;tee $461,00W " PERMISSION IS HEREBY GRANTED TO:
Cons 'lass
Contractor: Licenser
j I,IJse Uroup_ " Robert Hamel General Contractor-Salem#1566
1 Lot Slze(sq f[) 6400 Owner: GAUTHIER MAURICE A'
j �Z-omng_' Rl : Applicant: Robert Hamel -
� ;UmL G,.uted
.IAT: 0027INTERVALE ROAD
ISSUED ON.- 09-Aug-2001 - EXPIRES ON: 09-Feb-2002
I _
TO PERFORM THE FOLLOWING WORK:
Construct new single family dwelling:per plans submitted:'.P.S:
POSTTHIS CARD SO IT IS VISIBLE FROM THE STREET - -
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
(Underground: Servicer Meter: Fooiings:
rvi ;
*,.
Rough�� I �C(_ L, Rough //O1� House# Foundation: '
/�/ d "' Rough Frame::
Final" ./_�`d `2L ` Final:
Fireplace(Chimney:
Insulation:
Gas
Fife De artme Final:
Board of Health
L J0"
' Y 4 A
V2-Z to 1, Treasury:
Final: �+' Smoke Excavation: -
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VI AT N11 NY F
ITS RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2002-000158 09-Aug-01 1478 $461.00
Call for Permit to OCCUPY -
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO
HEALTH AGENT 120 Washington Street 4th floor
Tel: (978-741-1800)
Fax: (978)745-0343)
WATER QUALITY TESTING REQUIREMENTS
AFTER THE WELL HAS BEEN COMPLETED AND DISINFECTED,AND PRIOR TO USING IT Al�:
A DRINKING WATER SUPPLY,A WATER QUALITY TEST SHALL BE CONDUCTED.
A WATER SAMPLE SHALL BE COLLECTED EITHER AFTER PURGING THREE WELL
VOLUMES OR FOLLOWING THE STABILIZATION OF THE PH,TEMPERATURE AND SPECIFIC
CONDUCTANCE IN THE PUMPED WELL. THE WATER SAMPLE TO BE TESTED SHALL BE
COLLECTED AT THE PUMP DISCHARGE OR FROM A DISINFECTED TAP IN THE PUMP
- DISCHARGE LINE. IN NO EVENT SHALL A WATER TREATMENT DEVICE BE INSTALLED
PRIOR TO SAMPLING.
THE WATER QUALITY TEST, UTILIZING EPA METHODS FOR DRINKING WATER TESTING
(SOO SERIES METHODS) AND NOT METHODS USED FOR ANALYZING WASTEWATER,
SHALL BE CONDUCTED BY A CERTIFIED LABORATORY AND SHALL INCLUDE ANALYSIS
FOR THE FOLLOWING PARAMETERS:
Parameter Maximum Contaminant Level (MCL)
'Coliform Bacteria Positive sample
Parameter Recommended Upper Limit Lower Limit
Alkalinity 100 mg/I 30 mg/I
Calcium 150 mg/I 50 mg/I
Chloride 250 mg/I n/a
Color 15 color units n/a
Copper 1 mg/I n/a
Hardness 200 mg/I 50 mg/I
Iron .3 mg/I n/a
Magnesium relative scale
Manganese .05 mg/I n/a
Odor 3 TON n/a
pH 8.5 6.5
Potassium relative scale
Sediment visual Observation
Sulfate 250 mg/I n/a
Total Dissolved Solids 500 mg/I n/a
CITY OF SALEM HEALTH DEPARTMENT
Salem, Massachusetts 01970
mora
Volatile Organic Compounds
Parameter Maximum Contaminant Level (MCL)
Benzene .005 mgll
Carbon tetrachloride .005 mgll
Dichloromethane .005 mg/l
o-Dichlorobenzene .6 mgll
p-Dichlorobenzene .005 mg/I
1,2-Dichloroethane .005 mg/1
cis-1,2-Dichloroethene .07 mg/1
trans-1,2-Dichloroethene .1 mg/1
1,1-Dichloroethene .007 mg/l
1,2-Dichloropropane .005 mg/l
Ethylbenzene .7 mg/I
Chlorobenzene .1 mg/I
Styrene .1 mg/l
Tetrachloroethene .005 mg/l
Toluene 1 mg/1
Trichloroethene .005 mg/l
1,1,1-Trichloroethane .2 mg/l
1,2,4-Trichlorobenzene .07 mg/I
1,1,2-Trichloroethane .005 mg/I
Vinyl Chloride .002 mg/l
Xylenes (total) 10 mg/l
Inorganic compounds
Parameter Maximum Contaminant Level (MCL)
Antimony .006 mg/I
Arsenic .05 mg/I
Asbestos 7 million fibers/1
Barium 2 mg/I
Beryllium .004 mg/I
Cadmium .005 mg/I
Chromium (total) .1 mg/I
Cyanide .2 mg/I
Fluoride 4 mg/l
Lead (action level) .015 mg/l
Copper(action level) 1.3 mg/l
Mercury .002 mg/I
'Nitrate(N) 10 mg/I
"Nitrite (N) 1 mg/l
Total Nitrate & Nitrite (N) 10 mg/l
Selenium .05 mg/l
Thallium .002 mg/l
'indicates parameters that should be monitored once every year.
The most recent certified lab list can be obtained by calling the Wall Experiment Station at(978)682-5237
or by accessing the information at http://www.state.ina.us/dep/bspt/wes/wespubs.htni
Massachusetts Department'bf Environmental Management O q 13n o
Office of Water Resources
TYPE OR PRINT ONLY ', Well Completion Report
1: WELL LOCATION 41' GPS OPTIONAQ-K 1LATITUDE# �-4 '` `LONGITUDE ^� -
Address at Well Location: 22 71�)-TeKQA�2 R�D Property Owner.- " fes
Subdivision Name: Mailing Address:
1 —C� cdlf �• ,
City/Town: M b55 City/Towhr
/V
Assessors Map,�)- 007-2-0AssessorsLot #. 21 NOTE: Asse s�rs`Ma and Lot # mandatory if no street address available
Board of Health permit obtained: Yes Not Required ❑ I er-Pit Number �'C' ( D to e Issued
2. RK PERFORMED«.' - , a.. $..}=14 3. P PROPOSED USE•` �.; ..i e'i,"::..�. ` ¢. 4 DRILLING METHOD
New Well ❑ Abandon Er Domestic 171-,Irriga4on _l . 4t ; . JEU ble `"�❑jAuger
EJ Deepen E:1 Recondition El Monitoring ❑ Muniapa� Air Hammer N�:'❑ Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other I 11 MUd'ROta ti g ❑ Other
ti Unconsolidated ,
5. WELL LOG�,_�:� }A;, �COnSOIIdatE!.�--'6.:$t�'E,$KETCH (Use pertnerrent tantlmatka with tlist_snees)
W PemeabiI4 _
Q m rn as �, r fl
From (ft) To (ft) High Low N g m Other Rock Type -
5 , .�,
1„
7.1WELL CONSTRUCTION j*?pqy
Total Depth Drilled D/ From (ft) To (ft) Casing Type and Material Size,rO.D.,(In) Well Seal Type
Date Drilling C mpl to 1 (J t ;lee al✓ SAoe
9 SCREENO ;, a A:. ` 5: - x ` w '3R 4 ;.rt#. s ,. .3 • ;,a. ".'g
From (ft) To (ft) Slot Size Screen.Type and Material Screen Diameter
/V1 P
10.'FILTER PACK/GRO T/ABA ONMENT„MATERIAL e-41$„l) w P'y 2pN ¢ri#3p 11 ADDITIONAL-WELL INFORMATION A_,?
Developed? Yes ❑ No
From (ft) erial Description-NPurpose Fracture
a rg Enhancement? ❑ Yes ❑ No
,Wrs Method
C F SALEM Disinfected? ❑ Yes ❑ No
12.WELL:TEST At CTION WELLS)” k p z % 'l .* - `-Wj 13:'STATICWATER LEVEL(ALL'°WELLS)`44
Yield.,"Time Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (hrs' m (Ft. BGS) (his & min) (Ft. BGS) Date Measured Ground Surface (FT)
ul ;r 1 ao'*l /o
14. PERMANENT PUMP(IF AVAILABLE) 15:NAMEIADDRESS OF PUMP INSTALLATION COMPANY'I
Pump Descriptions to-e2 t Horsepower
Pump Intake Depth - }<A (ft) Nominal Pump Capacity (gpm)
16.'a66MMENTS"; "�
17.'.WELLDRILLER'S STATEMENTfLi*ji This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this report is,poo7m-plete and,correct to the best of my knowledge.
Driller / / Supervising Driller Signature:_•�/��� � �� Registration #:I . I
Firm: �' � ✓/Jt) Wr -f A141 Date: ✓�342 Rig Permit#: fI
NOTE. Well Completion Reports must be filed by the registered wed driller within 30 days of well completion.
BOARD OF HEALTH COPY
05/08/2002 -17:16 19789211556 SALEM PLMG PAGE 02102
l +
Cuno Water reatment
12628 US 33 North, Churu usco, IN 46723, US
Phone: (260)893.2141
Fax: (260)993-39
Water Analy i R WaterTreat ant
nnrt worm
° Report /1: 02042 -3
Distribu or Information
Dealer Information
88lem Plumbing
Phone: (978) 921-1200
Fax: Robert Hamel Customer Information
Phone: (978) 884.7457
People; 3 APPIlcation Data
_I
PumBathrooms: 2.5 p Rate: 15.8 gpm Pressure Tank: Air to ste
Pump Type: Submersible
Lab Test Results
HARDNESS; 17.0 gpl IRON: 0.40 ppm
TANNIN: ,0 40 ppm MANGANESE: 0.10 PPm "pH; 7,70
IRON BACTERIA TDs: 430 ppm COLOR: ; Clear
SEDIMENT: No . TURBIDITY: 1:00ntu
ODOR: Absent
.'Nratio.OTE Reportatl pN lithe v lua oblamotl m lab tests actual on site ph level may ba tldfarenC:.8erora instauing equipment,veru H _
to OTE:
r h z z ulpmentiRec _
Y p least Itb on s
%
Te6 alrow s OTnrTlendatlon
Ina eavipnten[rorAnuMnOe Ion le based '
lnatQtleLon of the ieaDO knoded agwp ant to pa tolQv ih fie reavl(a of our kbor-,qry anatys-o end the IMarnretlon r p
whkrl_�pe nave ho knowkd e,/ fth that she con�emretlods are Wolin the gmltanemaf theequlpm®nh There a a e same Namp a aror enaWsir ahovM be pertdrrtfetl d :tp
verify(ne eppbeQaon inlet G NIe spedhe epplkeeery,,wnlpp may Caeee uniaw!adtiry parformen(.p of the feoommenQed a ul Whkn Cvna Water Tleatrrrent hes',.ggorrtral
ZOOM Info mMlon,we r enQlyslQ end thlOQa aueh'.ae Weauew pjgiXl rete end Proper iNtanb(lyn, Luna q pmenc It k therefore the reepanalbinty of mpp seller to
! n enProper Intro soon or Che m Water treat.,put"e ria tkoniry terepNpment Ineretlea ba eI on
{ n0.1Po VJQLQr quegry We amFinake every rassonsbk effort m eaeut In carreQ[ng anY Probbme,theo my barub
Water Softener h , NS—US),I10'01 (� V H, i �'t ` - �r
�, q. ., -
I
r- Additional Information
Suggest trying en actl ated`carbon cartridge type filter at a single
successful, a larger w Is systtap to attempt removing bad taste and odor,
em_ carbon filter may be sized and installed.
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01/02/2002 09:09 9784920023 THgRSTENSEN LAB PAGE 01
��Za�2 a2a�o�i .enc.
66 LITTLETON ROAD,WESTFORD,MA 01886 (978)682-8396 FAX(978)692-0023 1-800-649-TEST
Report Number 61544 Report Date: 1/2/02
Client: Sample Information:
Avellino Well and Pump 27 Intervale Rd,
143 Main Street Salem,NH
Reading MA 01867
Sampled by: Client Date Received: 12/20/01 Date Sampled 12/20/01
Certificate of Analysis
Test Parameter EPA Limit Results Units
Total Coliform(P) 0 0 per100m1
Fecal Coliform/E.coli(P) Absent Absent perl00ml
Calcium �Sd —Ita No.Limit 52.7 mg/L
Copper(S) JA /. <0.02 mg/L
Iron(S) 0.3 . 'K'2� mg/L
Magnesium No Limit 21.9 mgt
Manganese(S) 0.05 � mg/L
Potassium No Limit 1.5 mg/L
Sodium See Note. - 47.9 mg/L
Alkalinity(S) (-J-6 —(G0) No Limit 97.0 mg/L
Ammonia-N No Limit 0.05 mg/L
Chloride(S) 250 187 mg/L
Chlorine No Limit <0.02 mg/L
Color(S) 15 tt 7,5� CPU
Conductivity No.Limit 7 umhos/cm
Hardness _'o—trop No Limit X222 mg/L
Nitrate-N(P) 10 0.24 mg/L
Nitrite-N(P) 1 <0.01 mg/L
Odor 3 1 TON
PH(S) 6.5-8.5 7.4 SU
Sulphate(S) 250 36.8 mg/L
Turbidity Not Spec. 6.0 NTU
Sediment pos/neg neg
Legends:
(P)=Primary EPA Standard,(S)=Secondary EPA Standard,#=Exceeds EPA Limit,
TNTC=Too Numerous to Count,*—Background Bacteria Noted,'=Exceeds Advisory Limit
Sodium Advisory Limits, Mass.=20,NH=250_
This water sample as submitted is considered SAFE to drink according to EPA guidelines.
However,one or more parameters exceeds secondary limits as denoted by the P sign.
Massachusetts Certification k MA048 Michael P.Carlson,for
Thorstenseo Laboratory Inc.
,�cuxwt CITY OF SALEM, MASSACHUSETTS
�N' BOARD OF HEALTH
3 e 120 WASHINGTON STREET, 4TH FLOOR S�
1 SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY LISOVIC7, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
February 8, 2002
Robert Hamel
28 West Avenue
Salem, MA. 01970
RE: 27 Intervale Road
Dear Mr. Hamel:
Our records at the Board of Health indicate that you have not obtained a Well Water
Supply Certificate. The issuance of a Water Supply Certificate by the Board of Health
shall certify that a private well may be used as a drinking water supply.
The following shall be submitted to the Board of Health to obtain a Water Supply
Certificate:
- copy of the well construction permit (B.O.H. has a copy on file permit#2-01)
- copy of the water well completion report (B.O.H. has copy on file received 2/02)
- copy of the pumping test report
- copy of the water quality report
This mailing includes a well water supply certificate application and water quality testing
requirements. There is no fee for this certificate. Also included is a form that needs to be
filled out regarding the pump that was installed.
Please call me at 978-741-1800 with any questions regarding this matter. Thank you.
Sincerely,
Jeffrey Vaughan
Sr. Sanitarian
yveil needs
' CITY OF SALEM, MASSACHUSETTS
- - BOARD OF HEALTH
120 WASHINGTON STREET,41° FLOOR
IQMBERLEY DRISCOL,L TEL. (978) 741-1800
NLWOR FAZ (978) 745-0343
Iramdin@salem.com
LARRY RAMDIN,RS/ItF.Iis,cl io,
I-II;AJ XII A(;I;,NT
Facsimile
Transmittal
To: 0 g
Fax # 1 I
RE: eC IrA ,�e,
Date : (� , I ( t
Page(s): including this cover#
Message:
Board of Health News --------------------------------------------------------------For Your Information
OFFICE HOURS:
Monday, Tuesday, Wednesday 8:00 AM to 4:00 PM
Thursday 8:00 AM to 7:00 PM
Friday 8:00 AM to 12:00 NOON
TRANSMISSION VERIFICATION REPORT
TIME 06/23/2011 23: 30
NAME
FAX 9787450343
TEL 9787411800
SER.# 000BON341991
DATEJIME 06/23 23:27
FAX N0. /NAME 915085651565
DURATION 00: 03: 02
PAGE(S) 09
RESULT OK
MODE STANDARD
ECM