1 Well Driller Report Massachusetts Department of Environmental Protection
Bureau of Resource Protection
Well Completion Reports
/S-3 Y/
Well Driller
Please specify work performed:
Hew Well
Please specify well type:
Monilonng
Number Of Wells:
11
Well Location
Address at well location:
Street Number: Street Name'.
1 DAMON ROAD
Building Lot#: Assessor's Map It
Assessor's Lott ZIP Code:
City/Town:
NORTHAMPTON
In public right-of-way: GPS (GPS for the deepest well)
r Yes r No
Subdivision/Property/Description:
Property Owner:
Engineering Firm:
WJF GEOCONSULTANTS
North: West.
4220445 72.38338
Mailing Address:
F click here if same as well location addres
Street Number. Street Name:
2789 BOSTON ROAD
City/Town: State'.
WLBRAHAM MASSACHUSETTS
ZIP Code:
01095
Board of health permit obtained:
r Yes M 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
(Direct Push
I Bedrock [-Choose Bedrock—
WELL LOG OVERBURDEN LITHOLOGY
From(ft) To(ft) Code
Color Comment
_• _1 I10 I Medium Sand - I Brown
PERMIT INFORMATION
DEP 21E RTN# DEP Groundwater Discharge#
ADDRIONAL WELL INFORMATION
Drop in drill Extra fast or Loss or addit
stem slow drill rate fluid
r YES C NO 1 : r Fast r Slowl C Loss r
Developed r yes G w! Are these wells nested?
Surface Seal Type Cement Area of group(sq.ft)
Total Well Depth 10 Depth to Bedrock
r Yes r W•
CASING ,r Is Casing above groundH
From To Type Thickness Diameter
O 'i 1 I Polyvinyl Chloride I-Schedule 40 2
SCREEN IF No Screed
From"> To
Fo
WATER-BEARING ZONES
From To
ANNULAR SEAL/FILTER PACK
Type
Slotted PVC
Yield(gpm)
From To Material 1"> Weight Material 2 Weight
Slot Size Diameter
Water
(gal)
-0 1101. I Sand . '., I, I--Choose Material--
WATER LEVEL
Batches Method Of Place
I Gravity
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Monitoring
Date Measured Static Depth BGS(ft) Flowing Rate(gpm)
11/04/2015 i5
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
and accurate to the best of my knowledge.
Driller BRETT BALYK Registration# 606
TECHNICAL
DRILLING
Firm SERVICES,INC. Rig Permit# 66
Monitoring IMI Supervising Driller Signature
Date Job Complete
NOTE.Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
NEWSHA
PETER,W
'.11/042015