158 Well Application & Permit BOARD OF HEALTH
City of Northampton
APPLICATION FOR A GROUND SOURCE HEAT PUMP WELL
CONST '-CTION PERMIT
GSHP Well Permit Nunrbeda1 � 10 be assigned by board of health)
Fee: $50.00 minimum for first well
$25.00 for each additional well
Total of GSHP Well(s) 2
This application must be accompanied by a scaled plot plan, produced by a civil engineer or
registered sanitarian showing adherence to the Underground Injection Control (UIC)
requirements(attached).
Application is hereby made to construct (X ) or repair( ) a GSHP well.
_Paul Helmuth and Joseph Greer _8/30/11
Owner's Name Date
(
CT Baker Hill Road 413-575-7244
Street Address Telephone Number
_Northampton, MA 01060
City, State, Zip Code
42.325785 —72.665194 approximate
42.325888—72.665108 approximate _
Location of Proposed Well(s)
(longitude and latitude)
230-095-001
Tax Map ° Parcel#
Signature oyAj icant Date
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
TO BE COMPLETED BY BOARD OF HEALTH
Penn
ZUL
issued t )
t
Daniel Wasiuk
From: Ben Wood
Sent: Friday, September 02, 2011 11:09 AM
To: Daniel Wasiuk
Subject: FW: UIC registration Northampton_158 Baker Hill Road
FYI,goes with the permit application in your mailbox
From: Cheung, Eric(DEP)fmailto:eric.cheunq(alstate.ma.usl
Sent: Tuesday, August 30, 2011 11:00 AM
To: Sue Streeter
Cc: Mike Simonelli; Gary Prior; Cerutti, Joseph (DEP); Ben Wood
Subject: UIC registration Northampton_158 Baker Hill Road
Hi Sue, Mike, and Gary,
The purpose of this email is to issue you Underground Injection Control (UIC) registration MASI 1A214208-5CL for the
installation of 2 closed-loop ground source heat pump(GSHP)well and system start-up at 158 Baker Hill Road,
Northampton.
The wells will be installed by Connecticut Wells, Inc.
This UIC approval is conditional upon meeting all of the requirements provided in the MassDEP Guidelines for Ground
Source Heat Pump Wells. This approval is for the installation of conventional closed-loop wells using high density
polyethylene(HDPE) tubing. If you are proposing the use of Rygan HPGX or Kelix well materials you must inform the
MassDEP UIC program of your intent to do so prior to installing the wells. Since MassDEP has not completed a detailed
review of this proposed installation, you are advised to contact me if you have any questions regarding the requirements
that are detailed in the guidelines. The guidelines can be obtained as the 3"'document on the following MassDEP UIC
web page:
http://www.mass.eovidee/water/drinkinetuic.htm
If you haven't already done so, a copy of the UIC application must be submitted to the local board of health. Please be
aware that the issuance of the above UIC registration number only indicates that MassDEP's UIC Program has received
the information that we have requested. There may be other local permits, ordinances, or regulations that apply, including
but not limited to board of health permits for well installations and building department regulations regarding trenching
work. The issuance of a UIC registration number by MassDEP does not supersede the requirements of any other state or
local regulatory entity.
A copy of this email has been sent to the local board of health. The board of health should be aware that as of Friday,
February 19, 2010, MassDEP significantly reduced the level of effort that goes into the review of a closed-loop UIC
registration application for a GSHP well. Specifically, MassDEP no longer requires that the applicant submit site plans
and proposed well construction details. Therefore, it is up to the applicant to ensure that all applicable set-back distances
are met per the MassDEP Guidelines for Ground Source Heat Pump Wells(August 2010).
If you have any further questions you can contact Joe Cerutti at Joseph.Cerutti(dstate.ma.us (617)292-5859, or by fax
(617)292-5696.
Eric Cheung
MassDEP
1 Winter Street, 5th Floor
Boston, MA 02108
E ri c.C h eu n q(a)state.m a.u s
ph 617 292-5992
fax 617 292-5696
FAX
CITY OF NORTHAMPTON
NORTHAMPTON
BOARD OF HEALTH
Fax to number:
413-789-2776
To:
Sue Streeter
Attention:
Date:
September 15, 2011
From:
Heather McBride
Number of Pages:
2
Additional
comments:
1)
NORTHAMPTON BOARD OF HEALTH
212 Main Street- Municipal Building
Northampton, MA 01060-3191
Phone: 413-587-1214
Fax: 413-587-1221
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City of Northampton
BOARD OF HEALTH
PERMIT NUMBER:0L00 " 013 FEE$
CHECK# i S 5
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CASH
This is to certify thatPRuL A_MUTh
NAME
&Mitts \usiPtit li.et-i
`5 E t- AM . . (ca 11$ QIOLIZ
ADDRESS
Is Hereby Granted a Permit to Install an
Ground Source Heat Pump Well:
LOCATION: � .A--
DATE: ,20A
oard of Health Director
This license is granted in conformity with the Statutes and ordinances relating
thereto and expires t * 1 3 2 Ct t---unless sooner suspended
or revoked.