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Massachusetts Department of Environmental Management 115595
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION GPS(OPTIONAL) PLATITUDE`"L_ *,;tt ';p _*4' LONGITUDE ' '"`'
Address at Well Location: 3 Pr'r S S � *Property Owner: ZVY/ 1V
Subdivision Name: N Mailing Address: Sall S ) 714
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City/Town:
Assessors Map ✓ Assessors Lot#; L NOTE. Assessors Map and Lot# mandatory 'rf no sheet address.available.< . . f,F
Board of Health permit obtained: Yes ❑ Not Require. d X Permit Number Dateassued' '
2. WORK PERFORMED s 3. PROPOSED USE :xr' ; °X,, _.., 4. DRILLING METHOD;, ` -
❑ New Well '❑ Abandon ❑ Domestic ❑ Irrigation ❑ Cable XjAuger
❑ Deepen ❑ Recondition D9 Monitoring EJMunicipal ❑ Air Hammer * 171Direct Push
X Replace ❑ Other ❑ Industrial E] Other El mud
Fio`ta :3.❑ Other
5, WELL LOG ¢ Unconsolidated Consolidated 6.SITE SKETCH (useoermanent taodmarka with aisran�).
Permeability a aZ m
>
From (ft) To (ft) High Low ° v n , g m other Rock Type EtflfY
O 5" Ilo —o
S lC) 16 �e
to )Z 5 x xL
r R,•.�11� � W a�
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7.WELL CONSTRUCTION - a.; 8. CASING7c%.r0jh
ft
Total Depth Drilled � From O 0 To (ft) Casing Type{arid Material Size O.D. (in) Well Seal Type —
Date Drilling ComRRtete ,ff D o2 0�' < oZ Fe I
SIj�'0`I
9.SCREEN x'f'".. :� `_. .. n... "'_<a .kw t�.�v-'z .. •* .. - b,' .. r ;- -�,... _ �t '�:'-
» s
From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
10. FILTER PACK/,GROUT/ABANDONMENT MATERIAL- 1;1f ADDITIONAL WELL INFORMATION . ;wM
r Developed? ❑ Yes No
From (ft) To (ft) Material Description Purpose Fracture
.r; NI,5 S°rrt A I PrO � FEnhancement?. ❑ Yes 121 No
Method �Y t� �'�Ln
Disinfected? ❑ Yes JN.No
12. WELL TEST DATA(PRODUCTION WELLS) _ RIA -jr ? ,. + 13.STATIC WATER LEVEL(ALL WELLS)
Yield NTtme Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM) (i rs,B min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
14. PERMANENT PUMP(IF AVAILAB E)r`• `05;"
=" 15.`NAMFJADURESS OF PUMP INSTALLATION COMPANY,
Pump Description _N&S�N Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm)
16.COMMENTS w
17. WELL DRILLER'S STATEMENT IThis well was drilled and/drNaband6ned un wfmy supervision, according to applicable rules
and regulations, and this ort i om dnd correct to the best of my knowledge.
0vz_�Upervising Driller Signature: Registration #: 131(0 im
DrilleroFirm:
z ate: d Rig Permit#:
NOTE. Well Completion Reports must be filed by the registered well driller within 30 days of weU completion.
BOARD OF"HEALTH COPY
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_ P.AY..2 ) 2004
x s CITY OF SALEM
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