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180 Well Paperwork BOARD OF HEALTH City of Northampton Well Permit Number 02607— O! Fee $50.00 APPLICATION FOR A WELL CONSTRUCTION PERMIT This application must be accompanied by a scaled plot plan, produced by a civil engineer or registered sanitarian showing the minimum distances required in Title 5 of the State Environmental Code. For new construction, requiring a septic system, the septic system plan submitted for the property in compliance with Title 5 requirements will be acceptable if the proposed well location is included. Application is hereby made to construct ( )or repair( rivate well. pIASSmnn ✓l Li I ) Lo1 Owner's Namd Date an ( A; r 5r, xi 3 sas-8� zf3 Street Address Telephone Number Ilorrkn n fl nn y O I o 6 0 City, State, Zip Code Location of Proposed Well (if different from address) For new construction: Septic system plan complies with Title 5: Septic system plan shows location of well: Tax Map fi Parcel # yes ( ) no ( ) n/a( ) yes ( ) no ( ) n/a( ) For new, repair or location to leach field, septic tank or city sewer: A scaled well construction plan has been submitted:yes Ono( ) n/a( ) Permit issued (date) Mail Application to: Northampton Board of Health 212 Main Street Northampton, MA 01060 C/ Date //A Permit expires one year from date of issuance CEPARTAEEVT'OF CONSERVATION AND RECREATION OFFICE OF WATER RESOURCES In accordance with the provisions of Massachusetts General Laws Chapter 21 Section 16 Bart C. Cushing is authorized to dig or drill wells in the Commonwealth of Massachusetts during the period 7/1/2006 To 6/30/2007 [)(rector. DCR Owe of Rater Resources Reg.No. 558 E:e'ld'.n DETACH CERTIFICATE ABOVE ALONG PERFORATION COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF CONSERVATION AND RECREATION COMMONWEALTH OF MASSACHUSETTS; DEPARTMENT OF CONSERVATION AND RECREATION WILL DRILLERS REGLSTRATION PROGRAM u9Ue this license to Bart C. Cushing ',IC'AEG NO. 558 S:GNED EFFEGTIVE. EXPIRES 7/1/2006 6/30/2007 I PUNCH CUT CARD '.3OVE ANL °_ACE !NI (oCR Section 2 Work Work Performed Performed Code Decommission DC Deepen DP Hydrofacture HF New Well NW Repair RP Replacement RE Section 5 Well Completion Report Codes Section 3 Well Type Well Type Code Cathodic Protection CTPR Domestic DMST Geocanstruction GCON Geothermal Closed Loop GTCL Geothermal Open Loop GTOL Industnal INDS Injection INJC Irrigation IRRG Monnodng MONT Public Water Supply PEWS Recovery RCVR Test Weiis TSTVJ Overburden Lithology Overburden Overburden Name (0B)Code Color Artificial FFl AF Black Boulders B Bluish Gray Clay CL Brown Coarse Sand CS Dare Gray Cobbles C Greenish Gray Fine Sand FS Light Gray Fine to Coarse Sand FCS Reddish Brown Gravel 0 Yellowish Brown Medium Sand MS Organics 0 Sand 8 Gravel SG Silt SI Silty Clay SICL Silty Sand SIS Silty Sand 8 Gravel 5150 1111 T Section 7 Screen Screen Type Code Caton Steel CST Continuous Wire PVC CWP Galvanized Wire Wrapped GINW Perforated Pipe PFP Prepack PVC PPP Pre-pack Stainless PPS Slated PVC SLP Stainless Steel Vee Wire SSV Stainless Steel Well Point SSP Overburden Bedrock Color Code Bedrock Name (BR Code) BL Amphibolite AM 60 Basalt B3 BR Conglomerate/Breccia CG/BR Diorite DI Gabbro GB Gneiss GN Granite GP Limestone LS Marble MA Quartzite OZ Rhydite RR Sandstone SS Schist SC Shale SH Slate/Phyllne SLUPH Pegmatite PM GG LG RB YB ,Section 8 Section 4 Drilling Method Drilling Method Code Air Hammer AH Air Rotary AR Auger A3 Cable Tool CT Casing Advancement CA Core CR Direct Push DP Drive and Wash DP/ Dug Mud Rotary Reverse Rotary Sonic 03 MR RR SN Section 6 Casing Type Type Casing Code Thickness NO CODE) Thickness Certa-Lou CTL Fiberglass FBG Galvanized Pipe GLP HDPE HDP NSF Coated Steel NCS PVC PVC Stainless Steel SST Steel STL Annular Seal/Filter Pack/Abandonment Bentonite Chips/Pellets Bentonte Grout Cement/Bentonite Grout Concrete Sand Native Material Section 12 Annular SeallFilter Pack/Abandonment Material Code Purpose BC FiN BG Filter CB Seal CT SD NM Pump Description Pump Description Code Horsepower 2 Wire Constant Speed Submersible 2WSS 1.2 20 3 Wee Constant Speed Submersible 3WSS 34 25 Constara Speed Submersiole Turbine CSST Venable Sneed Submersible Turbine VSST JET Line Shad Turbine LT Cenditicei CENT 1 1 1;2 2 3 7 1'2 10 15 53 vn '25 150 200 Purpose Code FL FT AS Schedule 5 Schedule 10 Schedule 40 Schedule 80 Schedule 160 GDR 13.5 SDR 17 SDR 21 SDR 26 SDR 325 SDR 40 179 19# Section 10 Method Method Code Air Blow wrth Drill Stem AB Bailing Constant Rate Puma Variable Rate Pump Slug Section 13 Well Seal Surface Seal Type Type Code Cent. 000 Cement.Benonte CB Concrete CT No,.= NO BL CR VA 5G TYPE OR PRINT ONLY Massachusetts Department of Conservation and Recreation Office of Water Resources Well Completion Report + 2r l, _l1 . . 1. WELL LOCATION I GPS (Required) North 51 :.)..2 1 9 . / West 7 0 ° 3 Co i G Address at Well Location 1 d F0.4 r S7 • E .q+ . Property Owner/Client IN Y1 (-t C IC ' I rt Q t=-.=;3 rY 10,fn Vh Subdivision Name: Mailing Address: I?Jr-) Fro _: r 31 C K} . City/Town: k It. r41'Y'x1V10rbY1 • fr0 )I.',G.C) Cily/Town'Alt r i in, , r r-v ■ M9 O /060 in Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address available Board of Health permit obtained: Yes 192( Not Required ❑ Permit Number Date Issued 2.WORK PERFORMED 3.WELL TYPE 4. DRILLING METHOD 6.CASING Overburden Bedrock From Pt) To (ft) Type Thickness Diameter u� J i N ` ' ,® !� I H +a 33n 0 © 'i. (qc • ❑❑ 5.WELL LOG OVERBURDEN Wate Bearing Zone Loss or Addition of Fluid Drop in Drill Stem Extra Fast or Slow Drill Rate ❑❑ . LITHOLOGY 7 SCREEN From (ft) To(ft) Code Color Comment From (ft) To (ft) Type Slot Size Diameter 6 0 ppn Olt- r Y /({. Y /� `I /(S1-; Y0i F / S F / S F / S _----- ❑ • • . --- G- V0 M5 r?/L ¥ / 7 • • • . V0 Do CL Y /(Ni • • • _ _ _ Y / N Y / N F / S 8. ANNULAR SEAL/FILTER PACK/ABANDONMENT MR. Y / N Y / N F / S From(ft) To (ft) Material Description Purpose Y / N Y / N F / S knfl /0 33E m Y / N Y / N F / S • • • ❑ Y / N Y / N F / S ❑ • • • YIN Y / N F / S ❑ • • • WELL LOG BEDROCK Water Bearing Zone Drop in Drill Stem Extra Large Chips Extra Fast or Slow Drill Rate Visible Rust Staining Loss or Addition of Fluid p of Fractures per foot D. SITE SKETCH- LITHOLOGY From (0) To (0) Code Comment ?7,0 Ycz2 [Yyrj2 5cl.9044 Carr i Y Q9 Y / NV / 5 Y /61,7 Y ACV .0j Y / NY / NF / SY / NY / N Y / NY / NF / SYINV / N Y / N Y / N F / S V / N Y / N Y / N Y / N F / S Y / N Y / N Y / N Y / N F / S Y / N Y / N Y / N Y / N F / S Y / N Y / N Y / N Y / N F / S Y / N Y / N Y / N Y / N F / S Y / N Y / N V / N Y / N F / S V / N Y / N 10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATER LEVEL(ALL WELLS) Yield Time Pumped Pumping Level Time to Geneve R covery Date Method (GPM) (hrs 8 min) (Ft. BGS) (hrs 8 min) ( 1. BGS) Date Measured Depth Below Ground Surface (ft) 7/tlPr? Aif 5, 0h _2:510_ 406 a4_:C tZ c.,Z0' ?f/Sja7 !S ' 12. PERMANENT PUMP(IF AVAILABLE) 13.ADDITIONAL WELL.INFORMATION Pump Description 0] Q 41 Ln Horsepower 1714 Develop 4D N Fracture Enhancement Y (171-) Disinfected Y f N Surface Seal Type h" ZI • Pump Intake Depth 3.20 (ft) Nominal Pump Capacity C. (gpm) Total Well Depth 400 Depth to Bedrock 3-4O 14. COMMENTS I 15.WELL DRILLER'S STATEMENT IThis well was drilled, altered, an r ab ndoned under my Supervision, according to applicable knowledge. rules and regulations,and this r compl safest to the best of my 7 `lit RA/1 �_l:_i^,: f '/ Supervising Driller Signature: .//i' "L` % Registration #:I S I S I " I I Driller. Firm- L G. CUSHING ; & SONS, INC. Date complete: - '� 2 r /t y/ ' Rig Permit#: 1 r-'I ti l,__+I I NOTE: Well Completion Reports mast be filed by the registered well driller w BOARD OF HEALTH COPY 30 days of well completion. f Dnnkine Well Permit Payment Record Date--4«/1,7/0 7 Amount: $ 6o.dad Cash Check# /0 '7 property 0 wner/124 I[ 'o,Q Property Address/Location 7,h fGq/ S •/f/02� / Se;'.Construction Repair ir,�ylAl6iJ,Gb JONATHAN C PLASSMANN ANGELA PLASSMANN 180 FAIR STREET,EXT. NORTHAMPTON,MA 01060 1007 ), sa-00982ne / OPANCH a FR 7>7/ $ r , EASTHAMPTON SAVINGS BANK LI: 21 La 709351: 409579 25 • City of Northampton BOARD OF HEALTH PERMIT NUMBER: CO 7 617 FEES 521 ca CHECK# !0 57 CASH This is to certify that zia 44-,1364d4.442.4 N 10 Fa.e 5tr t- Jv a-4i. /12•4 ADDRES Is Hereby Granted a Permit to Install an Individual Private Drinking Well: LOCATION:/0!/ a`4 5 wed 4)624 iQi n,te This license is granted in cfoJnform� ity with the Statutes and/or Ordinances relating thereto and expires on Lt�A�S)1 ( '7 200• unless sooner suspended or revoked. ((N "•'t) DATE: ariet /7 ,2002 Ernest J.Mathieu,RS.,M.S.,C.H.O. Director of Public Health Northampton Board of Health