4 SZETELA LANE Lahr
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4°i FLOOR
KIMBER1,11Y DR-ISCOI1. rEL. (978) 741-1800
MAYOR FAX(978)745-0343
LRAMDIN@SALEM.COM
LARRY RAMDIN,RS/RFJiS,CI-10 CP-FS
HEAL.fH AGENT
Well Construction Permit Application
Fee: $180. Check payable to the City of Salem (no cash. No charge for monitoring wells)
Date:-2/27/12
Location;i,4 Szetela Lane, 20 Webb Street and 4 Fort Avenue (Rear), Salem, MA. 01970
Owner: City of Salem Address 93 Washington Street Tel.
Type of well: Monitoring Well Well use: Environmental Sample Collection
Well Contractor: Soil Exploration Corporation Pump Contractor: NA
Address: 148 Pioneer Drive, Leominster Address: NA
Massachusetts 01453
Phone: (978) 840-0391 Phone: NA
Reg. #:
Have abutters been notified? (y) No How?
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In the space provided below(or on back) show the location of the proposed well in relation to existing or proposed above
or below ground structures. A description of visible prior and current land use within (200) feet of the proposed well
location, which represent a potential source of contamination.
"Please see attached Site Plan"
Summary of Proposed Work
• One(1)well will be installed on the 4 Szetela Lane property(Map 41, Lot 243). The well is a replacement for a well that
historically existed on the property but has since been destroyed.
• One(1)well will be installed on the 3 Fort Avenue(Rear)property(Map 41, Lot 244). The well is a replacement for a well that
historically existed on the property but has since been destroyed.
• One(1)well will be installed on the 20 Webb Street Property (Map 41, Lot 245)
Estimated well depths will be 15 to 20 feet.
There is no fee for monitoring wells but a permit is required for installation.
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B.O.H. use only Check#: Check date: Permit#: Gv) /
Well const permit appl. UPDATED 5/23/11
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`Massachusetts Department of Environmental Protection
Bureau of Resource Protection
WELL DRILLER
Please specify work perfon�d- NPD 4
Address at well location:
New Well Cej / Street Number: Street Name:
SZEiELA IANE
Please specify well type:— Building Lo# �I f�Assessors Map
Monitodng Mr ' Z
ITY #:
1
OF SALEM L-------J I I
BOARD OF HEALTH Assessor's Lot#: ZIP Code:
NumberOf—Wells: ��
Cityrrown:
Well Location SALEM
In public right-of-way: GPS.(GPS for the deepest well)
G Yes 0'No North: West:
42.52675 — x70.88328
SubdivistordProperty/Description:
Mailing Address:
Er click here if same as well location addree
Property Owner: Street Number. Street Name:
446 —� MMREEr
Cityrrown: _ State:
Engineering Finn: M�„,E,,
TIGHEANDBOND MASSACHUSETTS
ZIP Code:
01608 —7
Board of health permit obtained:
r'Yes f'' Not Required
Permit Number: Date Issued:
1001 3/52012
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection–Well Driller Program
Well Completion Reports(Monitoring)
Well Driller - Monitoring Form
DRILLING METHOD
Overburden Direct Push Bedrock Choose Bedrock--I
WELL LOG OVERBURDENLIiHOLOGY
From, Drop In. Extra fast or slow Loss or addition of,
To(ft) -Code Color Comment.
MY; - - - - drill stemdrillrate: fluid
F Gran F➢I Brown r Ye E Fast , Slow C Lass f Atldigon
0 12 Organics J Brown __ r Ye !i* Fast ! Slaw ` Loss r Addition
�12 15 Fine To Coarse Sand Dark Gray r Ye fFast G Slow r Loss r Addition
PERMIT INFORMATION _
DEP 21 E RTN# DEP Groundwater Discharge#
ADDITIONAL WELL INFORMATION
Developed G Yes !:i No Are these wells nested? C Yes r No
Surface Seal Type Cement Area of group(sq.ft)
Total Well Depth 15 Depth to Bedrock
CASING ❑Is Casing atwve ground
From To Type _ Thickness Diameter
IJ C_1 Polyvinyl Chloride Schetlule 40
SCREEN I r No Screen
From- To Type _ Slot Size_ Diameter
15 15 Slotted PVC _� 0.010 L` � ]—J
WATER-BEARING ZONES
-From.. To
Yield
�(gprn—�)
L_J
ANNULAR SEAL I FILTER PACK
Water
From; To - Material 1 Weight Material 2 Weight Betche Method Of Placement
_ :(gal)
0O CemsntilentoniW Gmut --Choose Material___ L� Gravity
Material � ___Choose Material-- � � � Gravity
0
—157 ,d
Bentonite ChipslPellets --Choose Material--- Gravity
15 Sand --Choose Material— Gravity
WATER LEVEL
Dete Measured- Static Depth BGS(ft) Flowing,Rate(gpm)
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Monitoring)
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a
knowledge.
Driller �IxNJALD LEGER Registration# 806
Monitoring IM] rd❑ Supervising Dri
Firm SOIL EXPLORATioNC Rig Permit# 273
Date Job Com
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Addendum)
WELL DRILLER - ADDENDUM FORM
WELL COMPLETION ADDENDUM FORM MONITORING WELLS
WeII.ID - Well Depth Screen Screen
-
Interval FROM Interval TO GPS.Coordinates(WGS.1984)Degree Decimals
-
2 15 5 15 North: 42.52625 West: 70.88334
4r 15 5 15 North:.42.52603 West: 70.88267
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.