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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, HS,CHO
HEALTH AGENT 120 Washington Street 4"Floor
Tel: (978)741-1800
Fax:978-745-0343
Commonwealth of Massachusetts
City of Salem
WELL WATER SUPPLY CERTIFICATE
f
Location 41 Intervale Road
Owner Mark Fournier
Address . 41'Intervale Road
This certificate is granted in conformity with the statutes and ordinances relating
to water use certificates.;',. -
Certificate•# -01 - 01
Date issued,,- ~ 00 /28 /01
Health Agent
R
09/28/2001 06:30 7812869090 NORTHSHORESUILDERS PAGE 01
Sep 20 01 12:51p ►- 1
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66 L.TTLI TON ROAD.WES ORD,1AA01886 (9781692-6796 FAX(979)692-0023 1-SM-645-TEST
i pun Number 559 Report Date: 5)73/01
C lent, Samplc in ormanon:
A ellmo WL&Purr lbrk Former
I )\rain Si. 41 lmcrvale
R ading A 01667 Siknt,MA
ntpled by Client Wit Rece'ved'. Y18101 Dale Sanpled: 5/19.01
Ce1T1I100I0 0[34taiv$is
'1' t P eler F roil Re' bora
I C it Culifotm(F) 0 U per N)Ontl
i
17at Colifenn'E:oli P) Ab:cnl Absent per io0ml
CI .:iant No Limit S0.0 m8i1
C )Per(S) I .a 02 mglL
ItIt(S) 0.3M 0.36 mg!L
!�t gueliunl Nu Limit 18.3 mg;L
M t:gatuse(S) UAS 003 mg,l
F n»tum No Limit 3.1 mg,L
S lum Sc:Nutt 20.7 mg'l
A al.nay(S) --p0,10: No Limit 106 m8iL
Ai un0nia-N No Limn <.0.03 mg;L
CI WAV(SI 250 TO(i mg'L
C)Jorma No Limn I v mi;L
C1 15 11 50 CPU
(71 No Limit 4 umhtu'nn
H "Ines. Sj.ada -40 Limo 203 mgrl.
N iw, N(P) 10 0.26 mS-L i
N wc-N(P) 1 001 mg,L
0101 % 2 TON
Pt (S) 0.3-a:• 7.4 SU
$ Iphate(S) 250 34.3 mg/L
T` rbidiiv Not Spec. 4.5 NT IJ
14 irnent p:nineg ttrg .
L gcnda
())-Yriuuiy EFA 51a aid,(S)=3ecpnd2ry EPA Standard,A-Exceeds EPA Limit.
T TC=Too Xkooinoii In Cvant.'^Backgrourd Dncce.0 Noted,'-Exceed.Advisory Limit
5 Arun)Adctaury Lin Is,bias,.-20.Nib-230, i
T is water*ample s ibmincd is considered SAFE to dtink according to EYA guidelflles.
H )we ver.ono or mori gaienletets exceede sec(milaty limits as dcrtoted by P sign
asmchusetta C¢roti tion 4 MAQ:F klichael P.Galleon,for
Haiapstruc c:cri uatica a 2739 T,Iioratenaen Laborauuy Inc.
SEP 2,0 2001
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CITY OF.SALEM
HEALTH DEPT.
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AVELL .N #yii y �#
fINdV & xCER % ' SOVEREIGN BANKNEW EN
515,110-
%-NFREADNGMA01867 r' xt $ p 57
-.,--(781)944-5454 5f
7FREEWATERXOM
41
PAYTOTHE - nT& - ' -
ORDER OF
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00 56081i 1:0 110 7 5 L 501: 70 4000 586
_I
WELL CONSTRUCTION PERMIT
Location 41 Intervale Road
Owner Mark Fournier
Address 41 Intervale Road
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 # 4-01
Date issued
Health .Agent
Department of Envirfonrne`tal Management/Division of•Water Resources
• WELL COMPLETION REPORT
WELL LOCATIONpOrWA4'Y GEOGRAPHIC DESCRIPTION -
Address y� mlewple- r
;e` 30 N �3� E W of -
(feet) (Circle) (
City/Town 34 le1w 1/)terVp1e_
Well owner IQ,-I� jC`OUr^rl re r (Mad)
Address V' / N S E ® of
(mi.in tenths) (circle) qq
intersect wl Lanl)n e4ye
Board of Health permit obtained: yes no ❑ Ohd)
WELL USEWELLWELL DATA
Domestic LI Public❑ Industrial ❑ Total well depth
Monitoring❑ Other Depth to bedroc ft.
Water-bearing rock/unconsolidated material:
Method drilled le to'fl (y. eU
Description f r
Date drilled SIL - Water-bearing zones,
t
CASING 1) From 60 To �d
Type S�eC� ___2) Frorn ' To
Length _ IS ft.-Dia(I.D.) L in. - 3).From To
'length into bedrock �� eft. Gravel pack well! de.
-
Protective well seal: dia.
`L Screen: .
Grout ElOtherpr'✓C �'/�Q' Slot# length_from_to_
STATIC WATER LEVEL(all wells)
Static water level below land surface c7D ft. Date S 17 0
WELL TEST(production wells) / o
Drawdown ft. after pumping hr: )7 L min. at o gpm
How measured Recovery gb ft< after_ hr. 15 min.
LOG of FORMATIONS COMMENTS
Materials From To - g
Sa 1 / / /1
2 rot-k 10 , Joel Driller Pic�ae-/ e, ,? ,),o 0
Firm AvcIV,n0 tk)e I v 19a nF)
Address I `/3 N Z^n 't'
City/Town iI ne t IAF pir O lib 7
Supervising
�Driller
Reg.# lq 3/1/
� Signature of supervising registeretl well tlnller
Please print irmly BOARD OF HEALTH COPY
JVD ,
CITY OF SALEM
HEALTH DEPT-
I
i
IMPGRTANT MESSAGE
FO
A.M.
DATE TIME P.M.
M
OP (J.n
REA C NUMBER EXTENSION
❑ FAX
O MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
�
i QiC
SIGNED
ops FORIN40OB
i
- - -- ------ ----
I
- - --- ---- - S310N
i
IMPORTANT MESSAGE
FOR q
DATE TIME'a' P.M.
M
OF qq L p VIZ4
&MZ�
PHON //
E 7 l' �()�l. /-) Tal
AREA CODE NUMBER EXTENSION
Cl FAX
CI MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAG
All
SIGNED
= FORM 4009
�. MADE IN U.S.A.