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111 NORTH ST iiia -� <2r��) Massachusetts Department of Environmental Management 'e';). f Office of Water Resources 142260 TYPE OR PRINT ONLY ` - • Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE „ LONGITUDE DATUM / Address at Well Locatio : ) L Property Owner/Client: /-70n1 O id— i - Subdivision Na e: ,!0 I �- � Mailing Address: /�� ( 0 . r #a City/Town: !T City/Town: 14) 0?_� t �� l VW Assessors Map Assessors Lot#: r NOTE: Assessors Map and Lot#,mr+atnd tory 'rf no.street-address available Board of Health permit obtained: Yes ® Not Required Perm; N m r Vb �D I d 06 8' ❑ e u be � ate Is,P Q 2 WQRK PERFORMED _ , , �J 3.PROPOSED USE°f, . ,,XNP-;:,< " s 4. DRILLING METHOD EVNew Well ❑ Abandon ❑ D estic ❑ Irrigation I❑ Cable ©Auger ❑ Deepen ❑ Recondition Monitoring ❑ Municipal ❑ Air Hammer El Direct Push ❑ Replace ^ ❑ Other ❑ Industrial ❑ Other ❑ Mud<Roa" ❑ Other 5. WELL LOG Water Unconsolidated Consolidated 6r SITE SKETCH(use'Pem,a•eMlandmrkswmnasmnces)• Bearing a m d d Other Rock Type {� ;�� (� From (ft) TO(ft) Zones m o ig m Material Description W " e`i (� ' t l 1,0 4 IV d _ js 2'5 2no V. O Cl- OF SAL M -BOA TD-UFT-TU I-TH A)VM ST 7.WELL CONSTRUCTION .w•S 8:CASING :=', a. y, Total Depth Drilled ! From (ft) To (ft) Casing Type'and Material Size I.D. (in) Well eal Typ Date Com�le tt. u 9. SCREEN _ r- From (ft) To (ft) Slot Size Screen.Type and MaterialScreen Diameter QANN 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL= _W,, 11. ADDITIONAL WELL"INFORMATION Developed? ❑ Yes Qlmr From (ft) To (ft) Material Description$,W Purpose ` Fracture S �^ l Enhancement? ❑ Yes ❑ No Method f Disinfected? ❑ Yes ❑ No 12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRQDUCTIOKWELLS)_ 13. STATIC WATER LEVEL(ALL WELLS)- Yield Time Pumped Drawdown to Time to Recover Recovery to Depth Below Date Method (GPM) "'-`(firs & min) (Ft. BGS) (hrs& min) (Ft. BGS) Date Me sured Ground-Su ce (FT) 14.PERMANENT PUMP (IF AVAILABLE) 15.NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Descriptiong= Horsepower Pump Intake Depth (ft) Nominal Pump Capacity oA-�. (ODM) 16. COMMENTS � `" -� 4 17'WELL DRILLER'S STATEMENT' "° This wellwas drilled, altered, and/or abandoned under my supervision, according to applicable rules ahcl regulations, and this report is yomplete and corre_c_I to the best of my knowledge. Driller: / � / 0 ° Supervising Driller Signature. ' gf i Registration #:�� 2 Firm$O1` ioradon • Dates; Ri Permit#: 513 o Reports must be filed Wthe registered well dril er within 30 days of well completion. Leominster, MA 01453 ` BOARD-OF HEALTH COPY ' Ctry OF SALEM, MASSACHUSETTS BOARo of HEALTH • 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL 978-741-1800 Fax 978-745-OM LV W W.SALEI&COM Kimberley Driscoll JoaNNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT WELL CONSTRUCTION PERMIT Location: 111 North Street Owner: Motiva Enterprises Address: 111 North Street This permit is granted in 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#: 006-06 Date Issued: 5/25106 (Monitoring Wells) (TED Inc.— Reg. #560) HEALTH AGENT . $H" �, E M`W.fi„+ Ms- ''yyy 't9 • n a-yy �A ry a �,k Lr rs a 5. *o zo f 4*�' -s Tia r+s. .•4 ' S'rr rv,g'i N'�? ,R"r.°�sx ,N r��a 1�. +. `.. _1 J' R ✓,.ew h?t;e8n 7�J�.awi: �. CITY OF SALEM; MASSACHUSETTS s . �� $OARD of HEALTH rf s Y u -120 WA_SHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL 978-741-1800 FAX 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT WELL CONSTRUCTION PERMIT Location: 111 North Street Owner: Motiva Enterprises Address: 111 North Street 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 #: 006-06 Date Issued: 5/25/06 (Monitoring Wells) (TED Inc. — Reg. #560) HEALTH AGENT MAY 19 2006 7: 10AM HP LASERJET 3200 508-482-5560 p. 2 i 301'- EXPLORATION 197853 918 06/17!06 0Zi07pm P. 004 Jun 21 04 O1:5Ip Joanne soots Salem BOH 978 745 0343 p.2 CITY O MASSArAtUSE.TTS. . /�)/JV�.V b . ARO OF HEALTH ( 120 WAG"NGTf w STIKET.ATN fl nn• Sum,MA 01970-- - .97&741.1800 xe7e.7asosaa. . . - STANLEY J.USOYICZ,JR. JOANNE Scu rT, MPH,RS,CHO MAYO EALTH AGENT I Well Con5tructic n Permit Application Date: <1%7 Fee:$100. Chec payable to the City of Salem(no cash) Location- f H A�br{'41 S&V-Q+ Salem,MA. 01970 Oamer" { fin - _ Tal. , Type of weU: ';�O QVE W -uae f(1Gnic�oc1R41A)N[G Well Contractor. Soil Exploration Eorp. Funlpdn-- LpAsoiTU�cC;Sarerr (-cx(SoFhh�'. Address' 140 Pioneer Drive . Address:: . Ito -�y�� Phone, Leominster, M9- 0 453- Phone: Reg.M:, V688)M 40-0391 Have atwgers been not7 Wj jo Haw? -" fn fire space provided below(or on back)dwi i the locaf&I of the pmpww&rill in refaean to exiaMlg a prnpesadabalea.orflelawgmueal. AQaaortptlan a[tdslkle Arran andcwrtcar rand un wiHib(200)feel of proposed weJ Iwaf o,which repraserrfa,00t®ntiafswm of cartaminabon. - 11 }� There isnoolee kvmondorfngweUabWapam d-ismWiiiedfor Instaka w. . . . RAN u . only --rlhark 8'-- (:h"A dab'. Pard* .� Mile"oemK&PPI reuhed IIRSM2 2.. MRY 19 2006 7: 108M HP LRSERJET 3200 508-482-5560 P. 1 :r Enpar are:trenrc! ar o res ertcsr 1 r t c and comistendy. u6 1600 Boston-Providence Highway Suit 138 Walpole MA 02081. Ph:509404-1866 Fz:509404-1862 facsin ee To: zI Fax: 97k- 2si c Y3 From: OV1. Date: !;�((Celao CC: • 0 Urgent x For Review • •Camnent • op4miewy ❑P eam Recyd®t kall I% q wt 5 CL+ t� j olt S+C,f)clrt at j V\CLIACO £zlr yu.Ar t� r d 3 1j D 1 { a Ip W/O AST FORMER (PRE- 5). HEATING OIL UST TP STORAGE W/p AST W/ VENT / .,/� N ENCLOSURE v/ veer 0 0 R O SEPA ' CPARATOR STATION BUILDING 0 _Q" �� \ 3 ilk ONS DISCHARGE LINE 1 r D ° d a n , 11 m ' .a 44 P A 5 1 A CONCRETE ' -- ch FI 1 m RE PAINING WALL _— LO FORMER PRE-1972 0 CA �LIPLDING ^ MDNRORwe Neu 0 44 I-� 't — OVEFNIAp ElealTeC 2nc CONCRETE tJ MPT ° o CITP TEL�PuonE Rale 0rSPLEANSER UST ° ' 4 usT '1 SITE- PLAN N � 9 0 ° p 15fl Spl m I e a) ' m m u FORMER PRE-1972u __.rGtmE DRAWN er• lvM A) NCUPB 4Q GAS LISTS' i �7 DATE: Ais/pe NSMELL SERVICE.STATIONcn TP INORTH STREET ANpSCAPE ' ] CURB SPLEN, MASSACHUSETTS L(+NDSCAPE - F LANDSCAPE LANDSCAPE. NORTHf STREET (R'EUTE 114 )