259 Well Tests & Plans UIC Registration Application —Approval to Install
UIC ID#: MAS11A214301-5C2
Facility Name: Melnik Residence
Address: 259 Chesterfield Road, Leeds [Northampton]
Owner: Patrick Melnik
Operator: Same as owner
Contact: Same as owner
Well category: Open-loop ground source heat pump (GSHP)
Well type: Standing column (5C2 EPA Category (old category 5A7))
Number of wells included in this registration: 2 (1 standing column bedrock well & 1 system bleed dry
well)
Number of entry points included in this registration: 1
Chemical Additives: None
UIC registration application preparer: Patrick Melnik
Well driller: Michael Laroche, Kirke R. Henshaw, Inc.
System installer: Paul Violand
System designer: Paul Violand
Application prepared by: Patrick Melnik
This UIC well registration authorization for approval to install a Class V UIC well is contingent upon
meeting the following requirements:
The ground source heat pump system shall be installed with an automatic system shut-off device
in the event of significant pressure loss in the refrigerant system.
The heat pump discharge to the well shall not contain any chemical additives (i.e. water softening
chemicals or corrosion inhibitors).
Since the UIC well will also be used as a source for private drinking water, a residential dual check
backflow preventer shall be installed after the split between the potable water supply and the
GSHP supply, prior to the GSHP heat exchanger. The cross sectional sketch submitted did show
a check valve at the correct location but did not specifically refer to a residential dual check
backflow preventer.
As was shown in the submitted cross sectional sketch, a backflow prevention device shall also be
installed on the bleed line to prevent back siphoning from the perimeter drainage system. This
does not have to be a residential dual check backflow preventer.
Upon completion of the well and heat pump system you shall complete and submit a UIC Well
Completion of Construction Notification form (available through your eDEP account).
You are required to provide the above referenced UIC Registration number on all future
correspondence with the MassDEP Drinking Water Program (DWP) related to these wells.
All correspondence that is not submitted electronically through eDEP shall be sent to:
MassDEP/DWP, 1 Winter Street, 5Th Floor, Boston, MA 02108.
This registered UIC well and/or system shall be properly maintained.
No other activity is allowed, within the area of this registered UIC well that potentially endangers an
aquifer, as defined by the MassDEP/DWP as an underground source of drinking water.
Prior to receiving system start-up approval MassDEP requires that groundwater laboratory analytical
results from a raw water sample collected from the UIC well (standing column bedrock well) be submitted
to MassDEP. Laboratory results for total coliform bacteria from a post heat pump sample are also
required. See the Guidelines for Ground Source Heat Pump Wells for a list of the required laboratory
analytical work at the following web site:
http://www.mass.gov/eea/agencies/massdep/water/drinkinq/underground-infection-control html (3rd item
in the "Guidance" section on the main column). Please note that the raw water analytes shown in Tables
1 and 2 of Section 4.1 of the Guidelines for Ground Source Heat Pump Wells were recently revised and
now include the requirement that raw water laboratory analytical results for lead, copper, and nickel be
submitted to MassDEP prior to the issuance of system start-up approval. You will not have to retest for
the other raw water parameters listed in Table 1, as the laboratory results that you submitted for those
Page 2 of 3
Commonwealth of Massachusetts
Executive Office of Energy E. Environmental Affairs
Department of Environmental Protection
One Winter Street Boston, MA 02106•617-292-5500
DEVAI L PATRICK RICHARD K SULLIVAN JR
Gaverror
February 18, 2014
Patrick Melnik
311 Chesterfield Road
Leeds, MA 01053
Dear Mr. Melnik,
_evretary
PENNE- L RIMMELL
Lcnmssioner
Re: City/Town: Northampton
Residential Property Name: Melnik Residence
UIC ID#: MAS41A2147301-5C2
Program: Underground Injection Control (UIC)
Action: Approval to Install UIC Class V Well
The Massachusetts Department of Environmental Protection (MassDEP), Drinking Water Program (DWP)
received on February 12, 2014, the submittal of a BRP WS06 permit application, eDEP Transaction#
628303, for the registration of two UIC Class V open-loop ground source heat pump (GSHP)wells. The
purpose of this letter is to issue MassDEP approval-to-install two GSHP wells. This approval is only for the
installation of the GSHP well and is not an approval for system start-up. In all future correspondence
regarding this UIC registration please make reference to UIC Registration# MAS11A214301-5C2. See
the following two pages for additional details regarding this registration.
If you have questions, please contact me at 617-292-5859 or by e-mail at joseph.cerutti[cilstate.ma.us or by
fax at 617-292-5696.
Joseph Cerutti
UIC Program Coordinator
MassDEP Bureau of Resource Protection
cc: Michael Laroche, Kirke R. Henshaw, Inc., 130 Cummington Road, Chesterfield, MA 01084
Northampton Board of Health, 212 Main Street, Northampton, MA 01060
Northampton Plumbing Inspector, 212 Main Street, Suite 100, Northampton, MA 01060
File Name: Y:ADWPArchiveA BOSTON\Northampton-MAST 1A214301-5C2-UIC-2014-02-18-CLI.doc
This information is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617-292-5751.TDDK 1-866-539-7622 or 1-617-574-6368
MassDEP Website.Wv a massgovidep
Printed on Recycled Paper
parameters are acceptable. It was not clear whether or not the bacteria sample represented a raw water
sample or if it was collected from the discharge from the main heat exchange unit. Therefore, MassDEP
requires either a statement indicating that the bacteria sample was a post heat pump sample or an
additional post heat pump sample for bacteria analysis.
Based upon the information provided in the UIC application submittal, the GSHP bedrock well will be used
for the dual purpose of drinking water. Please be aware that the use of the well as a source of private
drinking water requires prior approval from the local board of health or health department. Also, a local
plumbing permit is required for the installation of the plumbing associated with the GSHP system.
The issuance of the above referenced UIC registration number is only for the return flow associated with the
GSHP discharges and does not constitute an approval for use of the standing column bedrock well as a
source for public or private drinking water purposes. There may be other local permits, ordinances, or
regulations that apply, including but not limited to board of health permits for well installations and building
department regulations regarding trenching work. The issuance of a UIC registration number by MassDEP
does not supersede the requirements of any other state or local regulatory entity.
Page 3 of 3
Patrick J. Melnik Sr., Esq.
Patrick J. Melnik Jr., Esq.
Mary E. Melnik Penney, Esq.
MELNIK LAW OFFICES
Attomeys at Law
110 King Street
Northampton, Massachusetts 01060
Phone: (413)584-6750- Fax(413) 584-6789
mein iklawoffices @gmail.com
February 19, 2014
Daniel Wasiuk
Board of Health of City of Northampton
212 Main St.
Northampton Ma. 01060
Re: 259 Chesterfield Road- Heat pump permit
Dear Dan,
patmelnik @gmail.com
patmelnikjr@verizon.net
marypenney07 @gmail.com
I obtained the approval from the state for the use of the well at 259
Chesterfield Road for combined domestic water and heat. The permit and
the supporting materials are attached along with the City permit application
and filing fee. Let me know if you need anything else to approve the permit.
Thanks.
Commonwealth of Massachusetts
Executive Office of Energy &Environmental Affairs
Department of Environmental Protection
One Winter St^Bet Boston, MA 02108•617-222-5500
February 18, 2014
C' 9D
wl.—rm_=IVVEL_
Patrick Melnik
311 Chesterfield Road
Leeds, MA 01053
Re: City/Town: Northampton
Residential Property Name: Melnik Residence
UIC ID#: MAS41A2147301-5C2
Program: Underground Injection Control (UIC)
Action: Approval to Install UIC Class V Well
Dear Mr. Melnik,
The Massachusetts Department of Environmental Protection (MassDEP), Drinking Water Program (DWP)
received on February 12, 2014, the submittal of a BRP WS06 permit application, eDEP Transaction#
628303,for the registration of two UIC Class V open-loop ground source heat pump (GSHP)wells. The
purpose of this letter is to issue MassDEP approval-to-install two GSHP wells. This approval is only for the
installation of the GSHP well and is not an approval for system start-up. In all future correspondence
regarding this UIC registration please make reference to UIC Registration#MAS11A214301-5C2. See
the following two pages for additional details regarding this registration.
If you have questions, please contact me at 617-292-5859 or by e-mail atjoseph.cerutti@ state.ma.us or by
fax at 617-292-5696.
Joseph Cerutti
UIC Program Coordinator
MassDEP Bureau of Resource Protection
cc: Michael Laroche, Kirke R. Henshaw, Inc., 130 Cummington Road, Chesterfield, MA 01084
Northampton Board of Health, 212 Main Street, Northampton, MA 01060
Northampton Plumbing Inspector, 212 Main Street, Suite 100, Northampton, MA 01060
File Name:Y:\DWPArchive\BOSTON\Northampton-MAS11A214301-5C2W IC-2014-02-18-Cadoc
This Information Is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617-292.5751.TDDk 1-666 762 or 1.617.574.668
MassDEP W ecstle'.wvrmass 9ov dep
Printed Dn Recycled Pape:
UIC Registration Application —Approval to Install
UIC ID#: MAS11A214301-5C2
Facility Name: Melnik Residence
Address: 259 Chesterfield Road, Leeds [Northampton]
Owner: Patrick Melnik
Operator: Same as owner
Contact: Same as owner
Well category: Open-loop ground source heat pump (GSHP)
Well type: Standing column (5C2 EPA Category (old category 5A7))
Number of wells included in this registration: 2 (1 standing column bedrock well & 1 system bleed dry
well)
Number of entry points included in this registration: 1
Chemical Additives: None
UIC registration application preparer: Patrick Melnik
Well driller: Michael Laroche, Kirke R. Henshaw, Inc.
System installer: Paul Violand
System designer: Paul Vinland
Application prepared by: Patrick Melnik
This UIC well registration authorization for approval to install a Class V UIC well is contingent upon
meeting the following requirements:
• The ground source heat pump system shall be installed with an automatic system shut-off device
in the event of significant pressure loss in the refrigerant system.
. The heat pump discharge to the well shall not contain any chemical additives (i.e. water softening
chemicals or corrosion inhibitors).
• Since the UIC well will also be used as a source for private drinking water, a residential dual check
backflow preventer shall be installed after the split between the potable water supply and the
GSHP supply, prior to the GSHP heat exchanger. The cross sectional sketch submitted did show
a check valve at the correct location but did not specifically refer to a residential dual check
backflow preventer.
. As was shown in the submitted cross sectional sketch, a backflow prevention device shall also be
installed on the bleed line to prevent back siphoning from the perimeter drainage system. This
does not have to be a residential dual check backflow preventer.
• Upon completion of the well and heat pump system you shall complete and submit a UIC Well
Completion of Construction Notification form (available through your eDEP account).
. You are required to provide the above referenced UIC Registration number on all future
correspondence with the MassDEP Drinking Water Program (DWP) related to these wells.
• All correspondence that is not submitted electronically through eDEP shall be sent to:
MassDEP/DWP, 1 Winter Street, 5'" Floor, Boston, MA 02108.
• This registered UIC well and/or system shall be properly maintained.
• No other activity is allowed, within the area of this registered UIC well that potentially endangers an
aquifer, as defined by the MassDEP/DWP as an underground source of drinking water.
Prior to receiving system start-up approval MassDEP requires that groundwater laboratory analytical
results from a raw water sample collected from the UIC well (standing column bedrock well) be submitted
to MassDEP. Laboratory results for total coliform bacteria from a post heat pump sample are also
required. See the Guidelines for Ground Source Heat Pump Wells for a list of the required laboratory
analytical work at the following web site:
http://www.mass.gov/eea/agencies/massdeo/water/drinking/underground-infection-controthtml (3rd item
in the"Guidance" section on the main column). Please note that the raw water analytes shown in Tables
1 and 2 of Section 4.1 of the Guidelines for Ground Source Heat Pump Wells were recently revised and
now include the requirement that raw water laboratory analytical results for lead, copper, and nickel be
submitted to MassDEP prior to the issuance of system start-up approval. You will not have to retest for
the other raw water parameters listed in Table 1, as the laboratory results that you submitted for those
Page 2 of3
parameters are acceptable. It was not clear whether or not the bacteria sample represented a raw water
sample or if it was collected from the discharge from the main heat exchange unit. Therefore, MassDEP
requires either a statement indicating that the bacteria sample was a post heat pump sample or an
additional post heat pump sample for bacteria analysis.
Based upon the information provided in the UIC application submittal, the GSHP bedrock well will be used
for the dual purpose of drinking water. Please be aware that the use of the well as a source of private
drinking water requires prior approval from the local board of health or health department. Also, a local
plumbing permit is required for the installation of the plumbing associated with the GSHP system.
The issuance of the above referenced UIC registration number is only for the return flow associated with the
GSHP discharges and does not constitute an approval for use of the standing column bedrock well as a
source for public or private drinking water purposes. There may be other local permits, ordinances, or
regulations that apply, including but not limited to board of health permits for well installations and building
department regulations regarding trenching work. The issuance of a UIC registration number by MassDEP
does not supersede the requirements of any other state or local regulatory entity.
Page 3 of 3
Transaction Number:628303;Submitted On:2:62014 11 31 59
Fee Amount SO
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Drinking Water Prog,ain
BRP WS 06 a,b,c
UIC Registration
3 ? 6
Certain types ofmodifications of existing registrations shall require payment This system is not currently equipped to assess those fees.
Therefore,the applicant should be aware that subsequent to submitting this application,MassDEP may contact you to inform you that a
fee is due.The most common situation requiring a fee is when additional wells are added after the initial LIC registration application
was submitted and approved by MassDEP.
A.General Question
Al.What well type do you wish to register at this time?
Well Category:Ground Source Heat Pump Well Type:open-loop-standing column
A2.Are there any well additives? r Yes At No
A3.Is the design injection rate greater than or equal to 100,000 gpd? r Yes/No
A6.Does the well construction or closure activity involve a drilled well? r Yes ANo
A7.Is the registration a result of the closure or conversion activity of a previously umeeistered well? r Yes No
.A8.Is the facility serviced by the well for 4 residential units or fewer? pr,Yes r No
B.Residential Property Information
Property Name:PATRICK MELNIK
Address:259 CHESTERFIELD ROAD
City/ own:l FFDS State:MA
C.Status of Activity(ies)Being Registered:
Current status of proposed discharge activity:
/Designed,but not yet constructed/modified
✓ Proposed activity partially completed or completed
✓ Proposed activity completed and active
Is the applicant requesting a waiver of the 30 day waiting period?
✓ Yes/No
Zip Code:010530000
D.Owner/Operator Information:
Owner Info:
Fist Name: PATRICK Last Name: MELNIK
Address: 311 CHESTERFIELD ROAD
City/Town: LEEDS State: MA ZIP Code: 010530000
Email pamaelniKygnvil coin
Owner's Leal Contact:
First Name: PATRICK Last Name: MELNIK
Phone#: 4135846750 Fax#: 4135346789
anal patmehlik(nrgnaiLcom
Opetnuv Info: Last Name: A7ELNTK
First Name: PATRICK
Address: 311 CHESTERFIELD ROAD 010330000
City Imam LEEDS State: MA ZIP Code:
Email: paonehui grviLcom
Operator's Local Contact: MELNIK Name: PATRICK Last Name:
Phone k: 4135846750 Fax 4:
41358467X9
Email: pamelnik(dgnrailcom
Oopership Type:
Private Public
r Industrial r Local
C Commercial r Regional
C Non-profit r State
PcC Federal
E.Designer: VOILAND
First Name: PAUL Last Name:
SELF Phone 4: 4133643210
Company Name: EMPLOYED
Engineer Licensee(if National 3rd party or manufacturer approval and ID WATER FURNACE
applicable): number.
S ) Email pvoilandr@iconmastnet
LSPk(if applicable):
F.Installer. Last Name: VOILAND
First Name: PAUL
Company Name: SELF EMPLOYED Phone n: 4133643210
National 3rd parry or manufacturer approval and ID number: o'hnd�?wmcastvet
Erna* pv '
G.Preparer Information: Last None: MELNIK
First Name: PATRICK
Address: 311 CHESTERFIELD 010530000
Cit .Town: LEEDS State: MA M ZIP Code:
Phone4: 4135846750
F ,I. patmehulkOg iLLcom
MA Engineer
License k(if LSP 4 Of applicable):
applicable):
H.Registered Well Driller(if applicable): Last LAROCHE
First Name: MICHAELE -
company Nellie:KIRR.HFNSPIAW, Phoned: 4132964725 Massachusetts Well Driller Registration d: 196
INC.
Email henshawwellsgaol.com
1.Site Information:
Water Supply: r Public $Private Sewer: r Public$Prvate
Are there any other current or proposed discharges on site?:
r Yes/No
Check any of the following that apply to this site: If yes.File Number
a.E Bureau of Waste Site Cleanup Priority Site
b-f-Bureau of Waste Site Cleanup Waiver Site
If yes,File Number
If yes,Federal 1D 4
is
c.si e cLm td Site
If the site s wnently being regulated by the Bureau of Haste Site Cleanup,check any of the following that apply:
I—Incident Response r Short Term Measure IT Activity and use limitations
Confimt that the applicant has checked that the site does not have any activity restrictions with respect to limiting discharges on the
sue:
2cer 214
✓ Restrictions 152 No Restrictions
Only enter the location of wells that will be used for the following well npc:
Location of Well,Latitude&Longitude are no longer optional data.
Well
Identification Latitude:
Number:
Longitude:
4120597
72.42318 u IL �L'
N(e.g.42.355767)Enter number.e.r.42.355767
W(Do not enter(-)sign in front of value,cg. LJAtt W t
71.060996)Enter number,eg.71.060996
43.10600 72.42308
N(e.g.43.355767)Enter number,e.g.42.355767
W(Do not enter(-)sign m front of value,e.g. Ley �&�
71.060996)Enter number,e.g.71.060996
Identify the method used for locating the latitudeznngitude coordinates for the UIC Class V well(s).
a.Type:
'<Approximate location of point of UIC Class V well(s)
✓ Approximate center ofdninfield(s)
✓ Approximate location of center ofwellfield(s)
r Approximate center rffacility(ies)
✓ Approximate center of area where discharges are located
b.Accuracy:
J ,Estimated horizontal accuracy is less than+/-100 feet
C Estimated horizontal accuracy is less than+1-500 feet
✓ Estimated horizontal accuracy is less than 1-1- 1000 feet
Provide a narrative description of the site and the feature to be permitted.As an example:"The site is on the west side of Main
Street,the third building north of High Street The disposal field lies 100 feet off the southwest corner of the building."
SITE IS LOCATED ON THE SOUTH SIDE OF CHESTERFIELD ROAD AT THE WEST END OF THE PASTURE.THIS
IS THE ONLY HOUSE LOCATED IN THE PASTURE AND THE NEXT HOUSE TO THE WEST IS GREATER THAN 600
FEET AWAY AND THE NEXT HOUSE TO THE EAST IS GREATER THAN 600 FEET AWAY.
See instructions for BRP WS06a,b,c registration form for more details regarding the necessary attachments.Include the following:
F Topographic or Orthophoto Map
F Design sheets
F MSDS sheets
F Site Plan(to scale)
F Existing analytical data
F Narrative Statement
F Equipment Specification Sheets
F Attach Well Completion Report(required for existing drilled wells)
F Cross sectional diagram depicting all underground components of the UIC system
I—Other information(see instructions)
J.Injection Well Information(include information for wells being registered for closure):
Registration: fl ndividual r Area(multiple wells with same well codes)
Number of Wells: _ Maximum Well 550
Depth:
UIC Well(s)Construction Date(for existing wells): 7/2/2013
Well Construction(check all that apply):
F DryweIl F Drilled Well I—Septic Tank T Dug Well
r Improved Sinldiole T Dainfield/Leachtcld E Trench Dram T Dustwater onto the ground
r Honzontal(only applies to certain ground source heat pump wells)
I—Other(Describe: 100 characters max)
Pan 3.4
Type of Well Seal(if GROUT Well Seal Grouts ROUT
applicable) MatenaL
List water pthfication unit types discharging to Class V well
Purification Unit Type:
LV FILTER
Maximum total ate of injection(gallons per minute). Average discharge rate(gallons per day)'
250
Number of entry points to existing system
n
Total Number of entry points for proposed system(include new wells and remaining existing wells):
2
Distance to nearest wetland or water body(feet); Distance to nearest septic system(feet);
enter N/A if distance is Seater than 200 feet enter N/A if distance is greater than 200 feet
A 150
Distance to nearest building foundation(existing or proposed)(feet); Distance to nearest property line(feet):
enter NIA if distance is Beater than 25 feet enter NIA if distance is greater than 25 feel
N/A N/A
List any treatment devices,process equipment,or heat pumps in place or proposed prior to the injection point(attach specification
sheets and include treatment devices in a cross section):
NONE
Depth to water table(feet): Depth to bedrock(feet):
5 27
Distance to nearest private drinking wator well(existing
Soil type(s)at side-e g.,fill,sandy 611,gravel,sand: or proposed)(feet);
TILL enter N/A if distance is greater than 1.250 feet
300
Distance to nearest Public Water Supply(feet);
enter N/A if distance is greater than 2.500 feet
N/A
Page 410
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Massachusetts Deparbnent of Environmental Protection
Bureau of Resource Protection
WELL DRILLER
Please specify work performed:
New Well .
Please specify well type:
Domestic
Address at well location:
Street Number: Street Name:
259 CFESTEfff]EID ROAD '..
Building Lot#: Assessor's Map#:
Assessor's Lot$: ZIP Code:
Number Of Wells: 01056
Well Location
In public right-of-way:
Yes NJ,,.
Subdivision/Property/Description:
Property Owner:
PATRICKIrELNIK SR. 1
Engineering Finn:
City/Town:
NORTHAMPTON
GPS
North:
:42 20597
West:
72.42315
Mailing Address
click here if same as well location address
Street Number: Street Name:
311 CNES1EPFIEDROAD-1i
City/Town: State:
tl$6 MASSACHUSETTS
ZIP Code:
!01056
Board of health permit obtained:
] Yes Not Required
Permit Number. Date Issued:
'201301 '6/102013
Massachusetts Department of Environmental Protection
Bureau of Resource Protection-Well Driller Program
Well Completion Reports(General)
Well Driller - General Well Form
DRILUNG METHOD
Overburden Bedrock
Air Hammer Air Rotary
WELL LOG OVERBURDEN LITHOLOGY
From To(It) Code Color Comment Drop in Extra fast or slow Loss or addition of
(ft) dull stem drill rate fluid
G 20 Ta Brown Yes at Slow Loss Addh■on
2D c. Ta _ Brown _99_9_ 1 Yes as Slow, Loss Addition,
WELL LOG BEDROCK LITHOLOGY
From
(ft)
To(fl) Code
27 IL6 Schist
,65 H ;iii ",Schist
111 1 I'157 Schist
157 13 9 'Schist
:219 :261 Schist
251 313 Schist
313 231 Schist
',331 ,356 Schist
369 ,490 Schist
ADDRIONAL WELL INFORMATION
Developed
Comment
BROWN YELLOW
YELLOW
IWHREmtow I
Ye
�iGRAY WiirlE II Yes
GRAY
Visible Extra
Drop in Extra fast or slow Loss or addition of
drill stem drill rate fluid Rust Large
Staining Chips
reS■ ' Fast SIOwI Loss Addition Yes Yep
Fast Slow 1 Loss - Addilion Yesl - Yesl,
Fast Slow
Fast Stove
Loss Additlnn Yeesles Yes
Loss Addition -"7 Yes!
Ye� Fast Slow Loss Addition _ `C S 'yep
GRAY MITE Yed Fast Slow. Addition Yes, Yep
WHITE GRAY
, I Ye 3y Fast Slow. Loss Addition Yee Yed
GRAY , Yes Fast Slow Loss Addition Yes Yes
WHITE GRAY I 7 Fan Sena! Loss Anhtion Vie'
7 Yes W Disinfected Yes No,.
Total Well Depth 440 Depth to Bedrock 27
Fracture
Surface Seal Type None Enhancement
Yes W
CASING - Is Casing aboveground? From: 1.5 To 1.5
From To Type Thickness Diameter Driveshoe
15 sCi Steel 171$ GO
SCREEN• No Screen
From To Type
Slot Size Diameter
1e
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(Generap
--Choose Screen Type--
WATER-BEARING ZONES DRY WELL
From To Yield(gpm)
149
PERMANENT PUMP(IF AVAILABLE)
--Choose Pump
Pump Description Horsepower
Desaiption--
Pump Intake Depth(ft) Nominal Pump Capacity(gpm)
ANNULAR SEAL/FILTER PACK
From To Material 1 Weight Material 2
Weight(galer(gal) Batches Method Of Placement
Choose Material Choose Material 1 1
WELL TEST DATA
Time Pumping Time To
Date Method Yield(gpm) Pumped Level (ft Recover Recovery (ft
(HH:MM) BGS) (HH:MM) BGS)
12/2/2013 j BI AS Sky/win DWI Stem _I6 1 •0200 1400 1 105:00 1 15
WATER LEVEL
Date Measured Static Depth BGS(ft) Flowing Rate(gpm)
7/2/2513 5 '6
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 a
knowledge.
Driller MICWW.LLPROGHE jj Registration 196 Monitoring IM] Supervising Drill
Firm KIRKE RHENSHAW1. Rig Permit 382 Date Job Comp!
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
Massachusetts Department of Environmental Protection - Drinking Water Program
Volatile Organic Contaminant Report
I.SAMPLE INFORMATION:
Lab ID#:
17002
Sample Name: Pat Melnik
City/Town:
voc
Page 1 of 2
LEEDS
II.ANALYTICAL LABORATORY INFORMATION:
Primary Lab MA Cert#:
Analysis Lab MA Cert.#:
MAD851
M-CT008
Primary Lab Name:
Analysis Lab Name:
Howard Laboratories
Subcontracted?(Y/N)
Premier Laboratories,Inc.
v
Lab method
DEP Location Name
Sample
Information
Sample
Acidified?
Dab
Collected
Collected By
BENZENE
259 Chesterfield Road
❑
0
(M)ulsple
(S)Ingle
(B)ew
® (F)inished
Yes lD 12/2/2013
Yes:EI No[E]
Routine or
Special Sample
Original,Resubmitted or
Continntllon Report
If Resubmitted Report,
(1)Reason for Res bmission
list below:
(2)Collection Date of Original sample
❑RS ®SS
ID Original 0 Resubmitted 0 Confirmation
0 Resample 0 Reanalysis 0 Report Correction
107-06-02
SAMPLE NOTES-Such as.if a manifold/multiple sample.list the source(s)that were on-line dudn9 sample collection.
NO
II.ANALYTICAL LABORATORY INFORMATION:
Primary Lab MA Cert#:
Analysis Lab MA Cert.#:
MAD851
M-CT008
Primary Lab Name:
Analysis Lab Name:
Howard Laboratories
Subcontracted?(Y/N)
Premier Laboratories,Inc.
v
Lab method
Date Extracted
(551.1 only)
Date
Analyzed
Lab Sample DO
LAB SAMPLE NOTES-Include Information as to whether sample was
diluted or additional contaminants detected.
524.2
BENZENE
12/5/2013
E312392
0.50
Was this
edbythple
Composlted by the Lab?
COMPOSITE SAMPLE NOTES-Please list the compwited so rces by DEP Source Code(XXXXXX X-0X),up lo five Individual sources.
Yes:EI No[E]
5
CAS#
REGULATED
VOL CONTAMINANT
Results
pg/L
MCL
Y91L
MDL
494.
7143-2
BENZENE
ND
5
0.50
56-23-5
CARBON TETRACHLORIDE
ND
5
0.50
75-35-0
1.1-DICHLOROETHVLENE
ND
7
0.50
107-06-02
1.2-OICHLOROETHANE
NO
5
0.50
10646-7
PARA-OICHLOROBENZENC
ND
5
0.50
79-01.6
TRICHLOROETHYLENE(TCE)
ND
5
0.50
71-55-6
1.1,1-TRICHLOROETHANE
ND
200
030
75-01-0
VINYL CHLORIDE
ND
2
0.50
108-90-7
MONOCHLOROBENZENE
ND
100
0.50
95-50-1
O-DICHLOROBENZENE
ND
600
0.50
156-60-5
TRANS-42-DICHLOROETHYLENE
ND
100
0.50
156-59-2
CIS-1,2-DICHLOROETHYLENE
ND
70
0.50
78-57-5
1,2-OICHLOROPROPANE
ND
5
0.50
100-01-0
ETHYLBENZENE
ND
700
0.50
100-02-5
STYRENE
ND
100
0.50
127-18-4
TETRACHLOROETHYLENE(PCE)
ND
5
0.50
108-88-3
TOLUENE
0.63
1000
0.50
1330-20-7
XYLENES(TOTAL)
ND
10000
0.50
75-09-2
DICHLOROMETHANE
ND
5
0.50
120-82.1
144-TRICHLOROBENZENE
ND
70
0.50
79.00.5
1,1,2-TRICHLOROETHANE
ND
5
0.50