28 VARNEY STREET - WELL COMPLETION REPORT Massachusetts Department of Environmental Protection
Bureau of Resource Protection
` Well Completion Reports
Ll
Well Driller RECEIVED
Please specify work performed: S E P U 2 2021 Address at well location:
New Well Street Number: Street Name:
CITY OF SALEM BOARD OF HEALTH 28 VARNEY STREET
Please specify well type: Building Lot#: Assessor's Map#-
Monitoring
Assessor's Lot#: ZIP Code:
Number Of Wells:
1
Cityfrown:
Well Location SALEM
In public right-of-way: GPS (GPS for the deepest well)
rYes l:No North: West:
42.51876 70.91181
Subdivision/Property/Description:
Mailing Address:
click here if same as well location address
Property Owner: Street Number: Street Name:
6 LANCASTER COUNTY
ROAD
City/Town: State:
Engineering Firm: HARVARD MASSACHUSETTS
OMNI ENVIRONMENTAL ZIP Code:
01451
Board of health permit obtained:
r Yes C-Not Required
Permit Number: Date Issued:
Massachusetts Department of Environmental Protection
Bureau of Resource Protection-Well Driller Program
Well Completion Reports(Monitoring)
Well Driller- Monitoring Form
DRILLING METHOD __
Overburden D ct Push Bedrock F Choose Bedrock
WELL LOG OVERBURDEN LITHOLOGY
IFrom{ft) 'To{ft) Code Color Comment Drop in drill Extra fast or I Loss or addition
stem slow drill rate of fluid
l 1 �� Silty Sand And Gra Brown _-�
• YES NO Fast Slow Loss Addition
�� �� Silty Sand And Gra�� Brown `' `'
YES NO Fast Slow Loss Addition
PERMIT INFORMATION
DEP 21 E RTN# DEP Groundwater Discharge#
ADDITIONAL WELL INFORMATION
Developed C Yes r"No I Are these wells nested? r Yes r No
Surface Seal Type Cement- � rea of group(sq.ft)
Total Well Depth 8 Depth to Bedrock
CASING L Is
From To rType Thickness Diameter Casing
above
Ponyl Chloride _ Schedule 40 I�J ground?
lyvi
SCREEN T_No Screen
From"> To Type Slot Size Diameter
0 I Slotted PVC
WATER43EAPJNG ZONES
From To Yield(gpm)
ANNULAR SEAL!FILTER PACK _
Water
From To Material V5 Weight Material 2 Weight (gal) Batches Method Of Placement
0 1� Native al —Choose Material— !, Gravity Materi
Bentonite Chips/Pellets r�� —Choose Material-- I Gravity
12 1 Sand - —Choose Material-- �' ,Gravity J
WATER LEVEL
[Date Measured Static Depth BGS(ft) ;Flowing Rate(gpm)
I
D8/10I2021 7
COMMENTS
5 WELLS INSTALLED
Massachusetts Department of Environmental Protection
Bureau of Resource Protection Well Driller Program
Well Completion Reports(Monitoring)
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 and
accurate to the best of my knowledge.
Monitoring[M] Supervising Driller Signature
NEWSHAM,
DrillerMATTKELLY Registration# 606 PETER,W
TECHNICAL
DRILLING Date Job Complete
Firm SERVICES,INC. Rig Permit# 67 OBI1012021
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.