9 WEBB STREET 9 tilES6 Sr,�:
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Massachusetts Department of Environmental Management 121275
Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1. WELL LOCATION r GPS (OPTIONAL) ="LATITUDE - °+ ` T ' LONGITUDE " ' '
Address at Wel(Location: 14h Property Owner: -
Sutidivi�jttn Name ,Q �A �1 ��� Mailing Address: � w
City/Town: a3E(�� » —�f? City/Town:
�`•# '
Assessors Map Assessors Lot #: ` NOTE: Assessors Map and Lot# mandataryrf no street address available
Board of Health permit obtained -Wes Not Required Permit Number Date Issued .
„.
2. WORK PERFORMED 3. PROPOSED USE,
Via" 14. DRILLING METHOD rm-.
n�Kew Well ElAbandon ❑ Domestic EJ Irrigation EJ Cable : '- .:G2'Auger
LJ Deepen ❑.Recondition EI JXonitoring ❑ Municipal ❑ Air Hammer's O Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud Rota _` ❑ Other
S. WELL LOG Cc Unconsolidated Consolidated 6. SITE SKETCH(uw permanem landmarks vmm distances)
-CLI Perineabifity m
From (ft) To.(ft) High Low N g m Other Rock Type d
LL
7. WELL CONSTRUCTION 8 CASING.*-Xz,, - £ ,*
Total Depth DrilledFrom-(ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date D illing mplete a (/ 1 I -F `
9."SCREEN
From (ft) To (ft) Slot Size Screen.Type and Material Screen Diameter
/ 0 vC 1 I
107 FILTER PACK/GROUT/ABANDONMENT MATERIAL 1vfiADDITIONALWELLINFORMATION, ®u
Developed? ❑ Yes ❑ No
From (ft) To (ft) Material Descript' n%, Purpose Fracture
5` S�tr�� ? I Enhancement_? E] Yes E-1No
L7 i .� LeV44 Method
Disinfected? ❑ Yes ❑ No
12. WELL TEST DATA (PRODUCTION WELLS) 137 STATIC WATER LEVEL(ALC WELLS)
Yield ',Time Pumped Drawdown to . Time Recovery to Depth Below
Date Method (GPM)� (Itts & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT)
r
14. PERMANENT PUMP(IF AVAILABLE) 15.NAMEIADDRESS OF PUMP INSTALLATION COMPANY
Pump Description + Horsepower
Pump Intake Depth (ft) Nominal Pump Capacity (gpm),
16. COMMENTS
17. WELL DRILLE 'S STATEMENT This well was drilled and/or abandoned under my supervision; according to applicable rules
-, and regulations, and this report is comp) e.and co ect,tothe bestof my knowledge.
�I
Driller: / Supervising Driller Signature: Registration #:I
'
Finn: c • Date: — Rig Permit#:
WOTEi ell Comple rs Reports m st be filed by the registered well ' within 30 days of well completion.
y'�^ - .• , - � ' BOARD OF HEALTH COPY -
MAR 13 2003
CITY r�SALEM H
BOARD - -
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CITY OF SALEM, MASSACHUSETTS
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BOARD OF HEALTH
• 120 WASHINGTON STREET, 4TH FLOOR
` SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location 9 Webb Street
Owner Fred Hutchinson
Address 15 Robinson Road, Salem, MA.
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 # 1-03
Date issued 3/03/03
(monitoring wells - 5) (TDS — Reg. #560) CJS
Health Agent ,
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T ii C II N I C A L ORILLING SERVICES , 1 N C .
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FACSIMILE TRANSMITTAL SHEET
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CITY OF SALEM BOARD OF I+CALTH
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Well Cnngfuctl2n Pefmd AAR!!catiQn
Date: %3103 ree: s, Check payable to the ehy 0f S91em(no Cash)
Location; Sa_�tem�,MA. 01970
Owner:; i—ajj Address
Type Of well � P 0C- well use' Grow 1ma 7Oki I P iv\q
welt Contractor. '7-DS Purnp Contractor S Eri 6
Address: PO t39XI(7 Sd'er jm fM Address: k1S (,crr'i-ess-'re-
Phone: q7,?_yZZ,000S II phone: 97� -7VS yS�9
Req A:
Have abutters been notified?40(y)^r• How? _
................................. ..: ,a__....,.....,: :,._-.
III(na.^paCC Pm-Ocd bclaw tw on baeN).how the loconan of the p 0900 weft N Wad,"to
wrisPng arproposed above of below ground atruclu es A descnptfon rvtslbte pjWr and curve+rt
lend use whhM(200)kat otrne p dpasa0 well tocatibn,wh c2CFptese t a pWeY9tFat source of
caMamerAl+w.. C33��
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9r0 H.use only Check a chtek date Permit N.
TOTAL P.02
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DEPARTMEQ'I'OFENVURONMENTAI,MANAGEMENT fi4h1
OFFICE OF NATER RESOURCES F-�
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0SSACjj1JSETTS WELL DIuL,,,p
CERTIFICATE
In accordauce with tlx; provisions of
4fassacilusens
General Laws Chapter 2'I Section 16
I _ _ Mark Zork� _ 1
d
i5 auQlurvrll to Ili * or rill wells
r
i+I Ilu• CtuanullIvNeallh of:4liv"sa 'huse lI"i {.lusher IIx period
�y7//11/20/02 'To 06/ 30/2003
t
Tit rtut !!h! .c.nnr Urirw„r
plat"Ifiv.d t1w, h4 wnurrs
Reg.No.560 - -=
t it� ��♦�`1 }A�`rf?ip{„,V1 v j t�'`W�41Y�1'v 9��� Y�� 7Q��4I ,4 )��Q,Q���. t {�>¢Y��I 1 d, 11�J��,�� r'�Yyry ��'l�N(4 h`j., +wY �
�.. `��f' > >T�`^`�w`y £�.:� F ydi��.yb&R�'k8^�,C�"#�.R^Y'��4�•{ `t vn�����N���Sri��e� R�Y �.���}k�X��r�� >�sta�l�lrha���i�lll�py�k
DETACH CERTIFICATE ABOVE ALONG PERFORATION
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF f
WELL DRILLERS REGRSTRATION PROGRAM
]me Ira Itense to
Mark Z,ork
LIC.tREG.N0. EFFECTIVE EXPIRES
560 7/1/2002 06/30/2003
SIGNED:
CAREFULLY PUNCH OUT CARD ABOVE AND PLACE IN YOUR WALLET