352 Geothermal Well Application & Plans BOARD OF HEALTH
City of Northampton
APPLICATION FOR A GROUND SOURCE HEAT PUMP WELL
CONSTRUCTION PERMIT
GSIIP Well Permit Number ho be assigned by board of health)
Fee: $50.00 minimum for first well
$25.00 for each additional well
Total#of OSHP Well(s) ,5
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).
Fee: $
Application is hereby made to construct ex)or repair( )a GSHP well.
Zi
0(c)Pitt SPKOULl,
Owner's Name
X39 keNrac:ck
Street Address
Pets/Ts/'l MA- earn-- 0931
1ot 31k
6/7- 965- 7793
Telephone Number
Date
City,State,Zip Code
350 c‘t lel Ravi Leeds MA (P l t p v u-&eAdi
Location of Proposed Well(s) Tax Map # Parcel#
(longitude and latitude)
ynizyt wat, pzi LtiAJG rNc. L1,87 /ae
Signatutti of Applicant l Date
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton,MA 01060
ii
TO BE COMPLETED BY BOARD OF HEALTH
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Permit issued(sate)
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Lynde Well Drilling, Inc
5345 Hinesburg Road
Guilford, VT 05301-8105
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OCT-30-2020 03:24 FROM:LYNOEWEU ORI_LING 1302-254-1276
Lynde Well Drilling, Inc.
5345 Hinesburg Road
Guilford,VT 05301-8103
(800)242-5516
tyndewelldrillinarri comcast.net
Northampton Board of Heath
Attn: Xanthi Scrimgeour
212 Main Street
Northampton,MA 01060-3191
Re: Ground Source Heat Pump Well Application
Robert Sprout(Property
352 Chesterfield Road
Leeds,MA
Dear Xanthi:
TO:141.53071221. P.1.
October 30,2008
I received our ID*from MA DEP today to go ahead with the geothermal project
at the above property.
The MP is MASIIA2142U1-5A70A. Ken Pelletier is the contact person in
Underground Injection Control who handles the applications. He said they do no issue
any actual paperwork until the installation is complete. If you have any questions,his
office number is(617)3484014.
If you could please fax our drilling permit as soon as it has been approved, that
would be greatly appreciated. Our fax number is(802)254-1276.
If you have any questions,please give me a call at(802)254-2250. Thank you.
�
Sincerely,
/
Mary Bancroft
Secretary
DIECEIIVE
u
OCT 3 1 2008
J
NORTHAMPTON BOARD OF HEALTH
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A GROUND SOURCE HEAT PUMP WELL
CONSTRUCTION PERMIT
GSHP Well Permit Number 01 (to be assigned by board of health) Fee: S (56
Fee: $50.00 minimum for first well
$25.00 for each additional well
Total#of GSHP Well(s) S
This application must be accompanied by a scaled plot plan,produced by a civil engineer or
registered sanitarian showing adherence to the Underground Injection Control(UIC)
requirements (attached).
Application is hereby made to construct(50 or repair( )a GSHP well.
Sp40Uu
Owner's Name
0239 �tNDet.cic s--re r
Street Address
/✓ewT&nl Avl- 6 ac/S?- a 93/
City,State, Zip Code
35a, dI,esFe;c,e Id Road Leeds M (Pot P
)G ( 31 ,
Date
6/7- %y- THY3
Telephone Number
Location of Proposed Well(s)
(longitude and latitude)
rei
t- ,vpE VJEU. 02i CuAJG Ztc
Signaturb of Applicant / Date
6.c/uelI
Tax Map#
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton,MA 01060
i(/' /ace
Parcel #
Lunde Well Drilling. Inc
5345 Hinesburg Road
Guilford, VT 05301-810:
a y ty.✓DE_
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TO BE COMPLETED BY BOARD OF HEALTH
IL-3-os (ol)
Permit issued(date)
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7 DEPARTMENT OF CONSERVATION AND RECREATION
OFFICE OF WATER RESOURCES
.,; SACHUSETTS WELL DRIL r
S
CERTIFICATE
In accordance with the provisions of
Massachusetts General Laws Chapter 21 Section 16
Gary C. Lynde
is authorized to dig or drill wells = `,
in the Commonwealth of Massachusetts during the period
7/1/2008 To 6/30/2009
N
h'' - .
Director,Dell Office of Water Resources
Beg.No.591
4's, ja. „z .T ,- S ;, �$ .'ti�..' ry �i„ t,a�.. Wr °.°' €?” vx ��:i X1.. .,.,`4✓
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LMassachusetts Depa
) rtment t of Environmental Protection
Bureau of Resource Protection - Drinking Water Program O
BRP WS06e Residential Units COPY
See Instructions
See Instructions
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
toa
See Instructions
(four units or fewer)
Registration of Underground Discharges to Injection Wells NI
Modification to an Existing UIC Registration (BRP WS-06e) El
UIC Registration Fee: check the appropriate category
t' WS-06e. Residential Exemption (for four units or fewer)
the following well types (typical residential activities) are exempt from a UIC registration fee:
5A7, 5D2, 5G30& 5X18
Transaction Type
Registration: g Initial-new registration ❑ Initial-existing registration ❑ Closure/Registration
Modification: ❑ Change of owner/operator
❑ Change in or additional well/code(s)
❑ Change in location well(s) ❑ Change in#of discharge wells(+/-)
For modifications(required)
UIC Registration ID#issued by MassDEP in the original UIC Registration
ws06e•rev.08/06
A. Residential Unit Information
For modifications, enter only new or revised information.
Ro(aeV+ Sproul
-
Property name/Private Resi ence
3sa tskr'{te14 fad
Property Street Address
PI A
State
Company name((if
ekny i
City/Town
(71 Woo E{w'v(ut..ats_
Zip Code County
Water Supply:
❑ Public
iSt Private
Telephone Number Email(optional)
B. Owner/Operator Information
For modifications, enter only new or revised information.
Ito6es7 srrwLL
Name of Owner
N 1Fo t
City/Town
(nf% 9cv- 7793
239
Street Address
/Fn/t
State
krndnck ski"
oaYSR - a931
Zip Code
Telephone Number Email(optional)
Ownership Type:
Private:g Private ❑ Commercial ❑ Nonprofit ❑ Other:
Public: ❑ Local ❑ Regional
❑ State ❑ Federal
specify
BRP WS06e-Residential Units•Page 1 of 5
Li!
See Instructions
See Instructions-
Table at end
See Instructions
See Instructions
See Instructions
See Instructions
See Instructions
See Instructions
See Instructions
See Instructions
wso6e•rev.08/06
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS06e Residential Units
(four units or fewer)
Registration of Underground Discharges to Injection Wells j?C]
Modification to an Existing UIC Registration (BRP WS-06e) ❑
C. Injection Well Information
For modifications, enter only new or revised information.
Registration: ❑ Individual or fS1 Area
Closed 1,43q- (;v 1 tM&c
Well Type
Well Construction(check all that apply)
❑ Drywell ❑ Dug well ❑ Cesspool
❑ Trench Drain Q Other(describe).
Type of Discharge:
❑ Geothermal Heat Pump-open(5A7)
❑ Groundwater Infiltration (5G30)
❑ Sump (5G30)
sA7
Well Code
Number of wells:
S
❑ Septic Tank ❑ Drainfield/Leachfield
IJ4UP WP/((S— c(useJ kby 6iea r+,w�
VI, Closed Loop Heat Pump(5A7)
Pr-apy/e/it GtycoL-
❑ Water Purification Discharge (5X18)
❑ Stormwater-roof drainage(5D2) ❑ Stormwater-other drainage
List water purification units discharging to Class V well:
r�IA
#of entry points to existing system #of entry points for proposed system
Total#of entry points to system
Depth to water table(ft) Depth to bedrock(ft)
So'
Distance to nearest private drinking water well(within 1250 feet)
Non/ f
Distance to nearest Public Water Supply(within 2500 feet)
fJu x✓2
Distance to nearest wetland or water body
Soil type(s)atsit
06a 002.
Month/Year of well construction
Name of nearest Public Water Supply
a5�a �
Distance to nearest septic system
D. Operational Status
Well Operation Status:
Designed, not yet constructed ❑ Under Construction
❑Active
❑ Temp. abandoned ❑ Conversion to another well type
❑ Partial Closure/conversion to another well type (well code)
❑ Permanently abandoned/not reported previously
BRP WSO6e-Residential Units•Page 2 of 5
Must be attached
-see Instructions
ws06e•rev.08/06
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS06e Residential Units
(four units or fewer)
Registration of Underground Discharges to Injection Wells
Modification to an Existing UIC Registration (BRP WS-06e)
E. Site Information
Additional Information required:
All additional information that is relevant to the installation or operation of this injection well and to the
determination of its potential to endanger underground sources of drinking water(USDWs)—
including a site map showing the facility and UIC well(s), on-site drinking water wells, all other on-site
discharges and the drains leading to the well and/or drainage area served by the well. MSDS sheets
for chemicals likely to be discharged into well must be submitted.
Who must register:
Any party who discharges to a Class V Well as defined in 310 CMR 27.00 must apply except those
listed as exempt from the registration requirement as per 310 CMR 27.07.
If you have not previously registered and you are closing the use of the well(s)for one(or more) uses
but want to continue using the well(s)for one(or more) uses you must mark the top of this form
Change in or Additional Well Code(s)and attach to this submittal a Pre-Closure Form for the
well(s)/activities being closed.
If you have not previously registered and you are converting the well from a"prohibited" use to a use
that is"authorized by rule°you must mark the top of this form Conversion Change in or Additional
Well Code(s)and attach to this submittal a Pre-Closure Form for the well(s)/activities being closed.
Who must submit a Modification Form:
If the Owner or Operator information changes you must notify the UIC program at least 30 days prior
to the change(s).
If you are adding wells(Area Registration); relocating the well(s), changing the discharge(Well Code)
to the well(s) or adding additional discharges Well Code) you must notify MassDEP at least 60 days
prior to the change.
If you are closing the well(s)and relocating the well(s)and are planning to have the same discharge
(Well Code), you must mark the top of this form Relocation of Well(s) and attach to this submittal a
Pre-Closure Form for the well(s)being closed.
Fee
Residential units(four units or fewer)effective 10/08/04 are exempt from the UIC application fee(no
Transmittal Form needs to be submitted)for residential activities. There is no application fee
associated with submitting a Modification application to an existing registration.
BRP WS-06e-Residential Unit(4 units or fewer)/Residential Activity—Fee Exempt
No Transmittal Form (or number) is needed when submitting a Modification to an existing
Registration.
There is no annual compliance fee associated with this Registration.
BRP WS06e-Residential Units•Page 3 of 5
wee ea V01110y4 0- 4-rues
Massachusetts Department of Environmental Protection
Bureau of Resource Protection- Drinking Water Program
BRP WS06e Residential Units
(four units-or fewer)
Registration of Underground Discharges to Injection Wells
Modification to an Existing UIC Registration(BRP WS-06e)
F. Affidavit
The Injection well(s)described above Is used for placement or injection of bukis into the ground. two
understand that this well Is subject to Inventory requirements and compliance with the regulations
under the Underground Injection Control Program established pursuant to the Safe Drinking Watef
Act PL.93-523, and emendenents,and I/we hereby serve notice that the well is proposed or In
service.
Inve agree:
1. That the well(s)described herein will net be used for discharges other than those described
above:
2 That IMe will notify the MassDEP Drinking Water Program/UIC Program(on fans provided by
the LAC program)if any of the information(including Ownership,Location or Type of discharge)
for the above well(s)changes, but before the change(30 days minimum notice on
ownership/operator and 60 day notice on ail other changes):
3. That Uwe will notify me MaSSDEP DnnIdng water Program/UIC Program(on forms provided by
the UIC program-Pre-Closure Notification Form)when the above well(s)is no longer In use, but
before abandonment and He a Post-Closure Notification Form whin seven days of completing
the closure with me LIE program.
4. That 1/we will maintain financial responsibility for the well described shove;are
5. That Uwe will provide a sampling tap(approved by MassDEP)and allow sampling at the point of
injection.
I/We certify under penalty of law that ewe have personalty examined and am familiar with the
information submitted in this document and all attachments and based on my personal knowledge or
Inquiry of those individuals immediately responsible for obtaining the information, Uwe believe the
Informaton Is true, accurate, end complete. Uwe ern aware that there are significant penalfies for
submitting false information, including possible fines and imprisonment
Date
Lynda Well Drilling, Inc
5345 Hinesburg Road
Guilford, VT 05301-8103
d�-JSZf c?J5t
mint 6aey c_yirdef
frw4 5 /
rdA_Gee UC_AppBRPWSOasdoc•rN OMCS BRP V. tl e-ReildentialUses•Pages eta
L Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Program
BRP WS06e Residential Units
(four units or fewer)
Registration of Underground Discharges to Injection Wells
Modification to an Existing UIC Registration (BRP WS-06e) ❑
Questions
Any questions may be directed to the UIC Program at(617)348-4014 or to the UIC Contact at your
Regional MassDEP Office.
Find your region: http://mass.qov/dep/about/region/findvour.htm
Submit Application to:
MassDEP
Drinking Water Program
1 Winter Street—9a' Floor,
Boston, MA 02108
Attn: UIC Program
MAILING ADDRESSES
UIC Program, MassDEP Northeast Regional Office(NERO),
205b Lowell Street, Wilmington, MA 01887
UIC Program, MassDEP Southeast Regional Office(SERO),
20 Riverside Dr., Lakeville, MA 02347
UIC Program, MassDEP Central Regional Office(CERD),
627 Main Street, Worcester, MA 01608
S7'
UIC Program, MassDEP Western Regional Office(WERO),
State House West,4th Floor, 436 Dwight Street, Springfield, MA 01103
UIC Program, MassDEP Boston Office,
One Winter Street—6"' Floor, Boston, MA 02108
SERVICE CENTER PHONE NUMBERS:
Northeast Regional Office
Southeast Regional Office
Central Regional Office
Western Regional Office
978-694-3200
508-946-2714
508-792-7683
413-784-1100 ext. 214
Send duplicate copies of all forms to:
Local Board of Health
Local Plumbing Inspector
ws06e•rev.08/06
BRP WS06e-Residential Units•Page 5 of 5
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