711 Well Completion Report 2004 R PRINT ONLY
Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
136027
LOCATION
I GPS(OPITIONAL)" -LATITUDE* _.".^""` '" -°-"`--tONGZTUDt
barn
ee rksi) i re. Do sj. ri 'I oL
Location to 1L q Vim.
w Property Owner
at Well LI 4 04.-tit 19J r' (f
ion Name: Mailing Address'
JO;1 c rn JS U\
n10 fZ"Y5(.,K, � I-'`.11 City/Town- I
on-
Assessors Lot SO- I NOTE: Assessors Map and Lot# mandatory if no street address available
rs Map
t# Date Issued
f Health permit obtained: Yes.LJ Not Required ❑ Permit Number
K > v. ISiOP ..E�117St
:1..D�41..1lIG METHOD
-
Well Abandon C Domestic C Irrigation
C
pen C Recondition • Monitoring El Municipal
C Cable C Auger
I4u Hammer C Direct Push
C Mud Rotary ■ Other
lace ❑ Other 0 Industrial C Other
L LOG
Q
I-
3
P aLl
Unconsolidated
Consolidated
&-SITE SKETCH Os*ma$*f rleAA
-
0
0
Other
Rock
it) To (ft)
°
-rj
W
'-h (mil Gv. t2.)
ilito
She
1J
o
High
tow
la
K
Type
}.5
ES .
SOFT
If-Ca
Well Seal Type
4 .) I
F cm (ft) To (It) Casing Type and M terial Size O.D. (in)
-ii'
)ep h Drilled
)filling Complete J
b
C
�O
Sire /
t 3..S
-e SAnc
(tt) To (tt) Slot Size Screen Type and Material Screen Diameter
I
it
MOOT
SEWN
Developed? C Yes C-tfo
Fracture
Enhancement? ❑ Yes C-NO
Method
(ft) To (It) Material Description Purpose
4
Disinfected? Yes El No
ELL
TEST DATAIPR
:-., ,.'-::: .,. : ; &„
.$TATK{IYfITEp
_.
Yield Time Pumped Drawdown to Time Recovery to
to Method (GPM) (hrs & min) (Ft. BGS) (hrs& min) (Ft. BGS)
Date Measured
Depth Below
Ground Surface (FT)
I S
it/A/
-77
ft l✓ IiFT
EMAANENT
PUMP OF
AVASABt+E1 _
IS Xt111Bh011BE8'R�Fp111R 18fA11A11KMtl�lll?$T
/nt Horsepower
21//R
A/
1 Description
i Intake Depth OR Nominal Pump Capacity (9pm)
OMMENTS
/ELL DRILLERS
STATEMENT -:
(This well was drilled and/or abandoned
and this repirt
and r my supervision,
is complete nd correct to
r.
according to applicable rules
the best of my knowledge.
Registration #'1C1 4 kSiSl
and regulations,
G LA
c %-S r, rl ( Supervising Driller Signature: of - ' - - 9
n _ a ....- "NE , ■), - — ., r /Tom %7-.247 - 62 /U Rig Permit#: 1alZI /IZ1
NOTE: Well Completion Repo must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY