38 NORMAN STREET 38 /VD�iI>7F1N ST
-
r ��
Massachusetts Department of Environmental Management 115609
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1."WELL LOCATION GPS (OPTIONAL) LATITUDE ' '•°=;LONGITUDE'"' e i
Address at Well Location t?�YO�t"fQ-K Cr«%_ Property Owner: - -
Subdivision Name Mailing Address
City/Town. d�/e,r,i City/Town:
Assessors Map" Assessors Lot#: NOTE: Assessors Map and Lot.# mandatory it no st e t address available
Board of Health permit obtained: Yes ❑ Not Required 9 Permit Number DateAssued
2. WORK PERFORMED Lx,Z y- 3. PROPOSED USE t 4.tlDRILLING METHOD21 '° ; `
09 New Well ❑ Abandon ❑ Domestic ❑ Irrigation ❑ Cable ---"N Auger
❑ Deepen ❑ .Recondition Pf Monitoring ❑ Municipal ❑ Air Hammer"�Q Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota ❑ Other
S. WELL LOG- ¢
ermeability Unconsolidated Consolidated 6,SITE'SKETCH (tlse perms wih
anent to wmsrr 'msmce
ns).,
Pr a d m
Q N N N m n .�
From (ft) To (ft) High Low Co g m Other Rock Type
O 3 X �+ i .
jilt
7. WELL CONSTRUCTION!4--%� , e VCASINGa `
v ; try x^
Total Depth Drilled / ' From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Dateomp to 5 �'cr f l�✓�� - . I/� ' Qin A0 7-0
W>�aG
9.SCREEN
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
'0/0 T rm�
10. FILTER PACK l GROUT l ABANDONMENT MATERIAL =- a 11.'ADDITIONAL WELL'INFOflMATION
`-''.�� Developed? Yes En-No
From (ft) To (ft) Material Description Purpose El
Fracture
✓ /� . r7 l�e%S� ec r/< Enhancement? E] Yes 91 No
/ rt N' ) +. ��¢ / Method
.f> ) Disinfected? ❑ Yes K—No
12.WELL TEST DATA(PRODUCTION WELLS) 5 113;STATIC WATER LEVEL(ALL WELLS)
Yield ``Time Pumped Drawdown to Time Recovery to P Depth Below
�'DateMethod (GPM) -(nrs& min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
I hl :Qsf tre
\� 5Y
14 PERMANENT PUMP(IF AVAILABLE) rN" ' r 15.NAMEIADORESS OF PUMP INSTALLATIONCOMPANY
Pump Description Horsepower
Pump Intake Depth �� (ft) Nominal Pump Capacity (gpm)
16. COMMENTS
17.,WELL D ILLER' TATIEMENT-,„i" , This well was drilled an or aband ned under m supervision, according to applicable rules
and regulations, and this port i romplet correct t he best of my knowledge.
Drille Supervising Driller Signature Registration #:i 13 I� 1�9
F '�VeN—dam �uv.y0o#kdaTu Zic%n0% i S S
Date: Rig Permit#:
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days ofwell completion.
{! Fi t(41Y Y •Y iY 4fi. C'14, 44, [i kiln Y f4Ri..(.
t e 5 i'a •F£Y}' S { F 6 F[a i .p • . . ` 1[ t S a t i4Ft' t B OAR D O F�H EA LT H.COPY a 1q t l {5v . '[ 1 .. 1 a F F[ c ti Y£ •T S k{k 4 i 4 t a • a W 4 F
AzzP(
Selo
6�9�0 Oh� looe
60 '
� 1
t �
^ Y