555 (Police Barracks) Title 5 Application/Permits 1999, Well Monitoring Forms 2015 Massachusetts Department of Environmental Protection
Bureau of Resource Protection
Well Completion Reports
Well Driller
Please specify work performed:
New Well ll
Please specify well type:
Monitoring
Number Of Wells:
Well Location
Address at well location:
Street Number: Street Name:
555 NORTH KING
Building Lot#: Assessor's Map#:
Assessor's Lot#: ZIP Code:
City/Town:
NORTHAMPTON
In public right-of-way: GPS (GPS for the deepest well)
f Yes t: Ncli
Subdivision/Property/Description:
North'. West:
4221258 72 38418
Mailing Address:
F click here it same as well location address
Property Owner: Street Number: Street Name:
997 MILLBURY
City/Town: State:
Engineering Firm: WORCESTER MASSACHUSETTS
ECS ZIP Code:
01607
Board of health permit obtained:
f yes f: Not Required
Permit Number: Date Issued'.
n
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
WELL LOG OVERBURDEN LITNOLOGY
From(ft) To(ft) Code
Bedrock
'r-Choose Bedrock--
Color Comment
0 1 115 -! I Fine To Coarse San I Brown
1 5 1 30 , IFine To Coarse San
PERMIT INFORMATION
DEP 21 E RTN# DEP Groundwater Discharge#
Drop in drill
stem
Extra fast or Loss or addit
slow drill rate fluid
r YES r No r Fast C Slow'i r Loss r
ADDITIONAL WELL INFORMATION
Developed .. r Yes G No l, Are these wells nested?
Surface Seal Type Cement X11 Area of group(sq.ft)
Total Well Depth 30 Depth to Bedrock
CASING Li—Is Casing above ground's-
From
0
- C YES r pp r Fast r Slow r Loss r
r Yes C Ib
To Type Thickness Diameter
'25 I Polyvinyl Chloride I Schedule 40
SCREEN r No Screen
From"> To
25 130
WATER-BEARING ZONES
From
To
ANNULAR SEAL I FILTER PACK
Type
I Slotted PVC
Yield(gpm)
From To Material 1"> Weight Material 2 Weight
Slot Size Diameter
Water
(gal)
Batches Method Of Place
0 'i 118 I Native Matenal - I --Choose Material-- 1
118 123 I_ I Bentonite Chips/Pellets Y r I-- Choose Matenal---
I Gravity
I Gravity
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Monitoring)
23 1130 '.., ISand I --.Choose Matenal--- ! ' IGravity
WATER LEVEL
Date Measured Static Depth BGS(ft) Flowing Rate(gpm)
11110612015 '
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 ERIC BOUCHER Registration#
TECHNICAL
DRILLING
Firm SERVICES,INC. Rig Permit#
606
66
Monitoring[M]
NEWSHA
Supervising Driller Signature
PETER,W
Date Job Complete
NOTE:Well Completion Reports must be fled by the registered well driller within 30 days of well completion.
11/06/2015
NORTHAMPTON. MA
COMMONWEALTH OF MASSACHUSETTS
Board of Health, NXt aR*Ia . MA.
002
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
aptication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(4 - ]Complete System ❑Individual Conponems
[..radon 16 North Kifg Street
Owners Name Dept of State Falice
Map/Parcel* State IbLice liar ticks
Address 555 North King Street
Lot*
Telephone* (413) 584-3000
Installers Name ffi
Designer's Name qty ,t1ry, Dr
Address 270 QTIIRnlcatjcn Way
Address 278 N3jn Street
Telephone* (508) 771-1174
Telephone* (413) 773-3642
nor Minter= , P n/ ( star Q cp
✓Pe of Building
welling-No.of Bedrooms b ll
rzrSSr Holding (ki
rher-Type of Building EdEla '
riser Fixtures
esign Flow(min req "red)
[an: Date Plan 1999
ids
Site UTitility ffi¢V clans
escription of Soil(s) N/A
tB Evaluator Form No.
Lot Size
No.of persons
sq.f.
Garbage grinder 00
Showers (x).Cafeteria( )
24306ED gpd Calculated design now 24306113
N/A
Design flow provided 2430 gpd
Number of sheets 2 (L1,12) Revision Date N/A
- NsU amtm State Felice Bartaks
Name of Soil Evaluator N/A Date of Evaluation N/A
FSCRIPTION OP REPAIRS OR ALTERATIONS Ramval Of scisting c-{tir take replace with ern rete rrainle, and
ccne sicn of *trite ssnitaiy satyr to public system via paw) statlml.
Samar corn tla i 1nirdt waited by City- Fending CEP FF✓jal
he undersigned agrees to install the above described Individual Sewage Disposal System In accordance with the provisions of TITLE 5 and
archer agrees •t • plat cysts.• operation until•Certificate of y_• ' •ce has been issued by the Board of Health.
igned �eAkegsfh. Date It C
tspections
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
/Ae//%i-4.rJ
I
CERTIFICATE OF C
MA.
PLIANCE
FEE a
scription of Work: O Individual Component(s) C Complete System
le undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned
_1755 Noe 9 e o ta
Is been installed in accordance with th sions of 310 CMR 15.00 (Tide 5) and"""th�����/e,,�a,,pproved design plans/as-built plans relating to
■plication No. .s%� dated Alf/ . Approved Design Flow.1 _(gpd)
/ / - Date:
smiler E('(n
esignec Inspector:
he issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 4/o2 o UCTN MA.
DISPOSAL SYSTEM CONS ION PERMIT
'ermission is hereby ted to; Construct( ) Repair( ) Upgrade( ) Abandon(ran individual sewage disposal system
as described in the application for
FEE N/-
kit s SS' NOa ,!/ &
)isposal System Construction Permit o. '.S'%4
Provided: Construction shall be completed within three years of the date of this e it.�cal condi must be met.
Z/alts Board of Health
dated 6//3/f'f
arm 1155 Pm.556 AM.SUIbn CO.Boston.MA
Date