888 Well Application & Forms 2007 Well Permit Number
BOARD OF HEALTH
City of Northampton
02n7- aI
Fee $
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(y) or repair( ) a private well.
A i r u v ( L ./z sic' 7
Owner's Name Date
S3 &.k, 2f-u4 SrSG -2:752.
Street Address Telephone Number
C)(ti, 1A- 171055
City, State, kip Code
`dSk C'Nark,-A & [2rr.), gnuct1W / <7
Location of Proposed Well Tax Map # Parcel #
(if different from address)
For repair or location with city sewer:
Scaled well construction plan has been submitted:
For new construction:
Septicsystem plan complies with Title 5:
Septicsystem plan shows location of well:
Signature of Applicant
Date
yes ( ) no () n/a(+cy
yes (2)<o ( ) n/a( )
yes (lino ( ) n/a ( )
1,20 7
Permit issued (date) Permit expires one year from
date of issuance
[5bn3
a
City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: DDri -Op
This is to certify that
F-8
FEE S Ora ' a
CHECK#J9
CASH
ADDRESS
f
Is Hereby Granted a Permit to Install an Individual
Private Drinking Well:
LOCATION:
This license is granted in con3ormity with the Statutes and/or Ordinances relating
thereto and expires on
suspended or revoked.
,2 q ,200/ unless sooner
Ernest J.Mathieu,RS., M.S.,C.H.O.
Director of Public Health
Northampton Board of Health
DATE: rti G7 ,2002
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Wayne G. di Frances M. Thibault
Book 1581, Page 738
7.087 Acres ,
LEGEND
O I.P. Ft
• I.P. TO I
A UNMARKEI
LOCUS REFERENC
HAMPSHIRE coUNTT'REGISTRY GI
GRAN EE-EI1.Aa APP
PROBATE DO T•90E0G2
PLAN BOCK 17i Pms gas..
Name: EASTHAMPTON
Date:5/14/107
Scale' 1 inch equals 2000 feet
Location: 042° 19'44.8" N 072°43'07,0" W
Caption: Proposed Infiltrator system
Cud. Rd. -"Old Mill Site'
Northampton, MA-M. Clapp
Copyright(C)1997,Mooted 1,Inc.
Customer:
John Clapp
P.o.Box 561
Leeds, MA 01053
62 Main Street, Bldg. 2
P.O. Box 68
Hatfield, MA 01038
(413) 247-5533
BORATORY TEST RESULTS
Laboratory Sample ID: 13064-1
Customer Sample ID: 888 Chesterfield, Florence
Date Sampled: 6-12-07
Time Sampled:
Date Received: 6-13-07
Time Received: 8:00
Parameter/Test Description
Total Conform Bacteria
E. Coll.
Fecal Conform Bacteria (Plate Count)
Reportng Limit
Comments
Present/ Absent
Present/Absent
0 calonies/mL
OK
Total Conform Batena (Plate Count)
6 colonies/mt. 235 colonies/ mL
OK
Iron
0.39 mg/L 0.30 mg/L
Manganese
Nitrate
0.092 mg/L 0.050 mg/L
0.20 mg/L
10 mg/L
OK
Nitttte
pH
Sodium
0.001 mg/L
6.7 Units
8 mg/L
mg/L
OK
6.5 - 8.5 pH Units
OK
20 mg/L
OK
Conductivity
0.06 mS/cm
Turbidity
2.76 NTU
Chloride
14 mg/L
Hardness
60 mg/L
No Standard No Standard
No Standard No Standard
250 mg/L OK
No Standard < 50 soft
100> hard
This sample meets acceptable standards of potability for the parameters tested
except those marked with an asterisk (*).
Please refer to the sheet attached for more information on how to disinfect your well.
Analyst: MMM
Date06-13-07_
7
td P0(07:90 9191> S2
\\ aktk. dip Selo ?
: 'ON xad
' W061
JUL - 3 2007
J
N
LA
Customer:
John Clapp
P.o.Box 561
Leeds, MA 01053
62 Main Street, Bldg. 2
P.O. Box 68
Hatfield, MA 01038
(413) 247-5533
BORATORY TEST RESULTS
Laboratory Sample ID: 13064-1
Customer Sample ID: 888 Chesterfield, Florence
Date Sampled: 6-12-07
Time Sampled:
Date Received: 6-13-07
Time Received: 8:00
Parameter/Test Description
Total Conform Bacteria
E. Coll.
Fecal Conform Bacteria (Plate Count)
Reportng Limit
Comments
Present/ Absent
Present/Absent
0 calonies/mL
OK
Total Conform Batena (Plate Count)
6 colonies/mt. 235 colonies/ mL
OK
Iron
0.39 mg/L 0.30 mg/L
Manganese
Nitrate
0.092 mg/L 0.050 mg/L
0.20 mg/L
10 mg/L
OK
Nitttte
pH
Sodium
0.001 mg/L
6.7 Units
8 mg/L
mg/L
OK
6.5 - 8.5 pH Units
OK
20 mg/L
OK
Conductivity
0.06 mS/cm
Turbidity
2.76 NTU
Chloride
14 mg/L
Hardness
60 mg/L
No Standard No Standard
No Standard No Standard
250 mg/L OK
No Standard < 50 soft
100> hard
This sample meets acceptable standards of potability for the parameters tested
except those marked with an asterisk (*).
Please refer to the sheet attached for more information on how to disinfect your well.
Analyst: MMM
Date06-13-07_
7
td P0(07:90 9191> S2
\\ aktk. dip Selo ?
: 'ON xad
' W061
HOWARD LABORATORIES
62 Main Street, Bldg. 2
P.O. Box 68
Hatfield, MA 01038
(413) 247-5533
LABORATORY TEST RESULTS
Customer: Laboratory Sample ID: 13129
John Clapp Customer Sample ID: 888 Chesterfield Rd., Florence
888 Chesterfield Rd, Date Sampled: 07-11-07
Florence, MA Time Sampled:
Date Received: 07-11-07
Time Received: 5:00
Parameter/ Test Description
Sample Result
Reporting Limit
Comments
Total Coliform Bacteria & E. Coli.
Absent
0 colonies/ 100mL
OK
This sample meets acceptable standards of potability for the parameters tested.
Analyst: MMM
Date: 07-12-07
Microbiology Certification No.: M-00851
�Y L S 1' ti
idJ=NC, • 1, M1r PI Y.:�mr r=iar � S>fS 9 -._Id r7Nn
DEI'AR NIENl 01° CONSERtAT1ON AND RECREATION
(IjTICIi OF CATER RFSOLRCES
In accordance with the provisions of
Massachusetts General Laws Chapter 21 Section 16
Kenneth C. Lynde
is authorized to (fig or drill wells
in the Commonwealth of Massachusetts during the period
7/1/2006 To 6/30/2007
Reg.No.480
Wye o,; OCI?Offer of bitter Resources
DEPARTMENT OF CONSERVATION AND RECREATION
OFFICE OF WAFER RESOURCES
In accordance with the provisions of
Massachusetts General Laws Chapter 21 Section 16
Gary C. Lynde
is authorized to dig or drill wells
in the Couunonwealth of Massachusetts during due period
7/1/2006 To 6/30/2007
Director DCR Office of Miter Resources
Reg.No.591
inP
w,
Section. 2
Work
Work Performed
Performed Code
Decommission DC
Deepen DP
Hydrofracture 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
Geoconslmction GCON
Geothermal Closed Loop GTCL
Geothermal Open Loop GTOL
Indusbial INDS
Injection INJC
Irrigation IRROO
Monitoring MONT
Public Water Supply PEWS
Recovery RCVR
Test Wells TSTW
Overburden
Lihology
Name
Adhicial F'JI
Boulders
Clay
Coarse Sand
Cobbles
Fine Sand FS
Fine to Coarse Sand FCS
Gravel G
Medium Sand MS
Organics 0
Sand 8 Gravel SG
Slit SI
Silty Clay SICL
Silty Sand SIS
Silty Sand 8 Gravel SISG
Overburden Overburden Overburden Bedrock
(0B)Code Color Color Code Bedrock Name (BR Code)
AF Black BL AmphiboliL AM
B Bluish Gray BG Basalt BS
CL Brown BR Conglomerate/Breccia CGIBR
CS Dark Gray DG Diodte DI
Gabbro GB
Gneiss• GN
Granite GR
—Limestone LS
Marble MA
Quartzite OZ
Rhyolite RH
Sandstone SS
Schist SC
Shale SH
Slate/Phyllhe SL/PH
-.Pegmatite PM
Section 7
Greenish Gray GG
Light Gray LG
Reddish Brown RB
Yellowish Brown YB
Screen
Screen Type Cade
Carbon Steel CST
Continuous Wire PVC CWP
Galvanized Wire Wrapped GWW
Perforated Pipe PFP
Pre-pack PVC PPP
Pre-pack Stainless PPS
Slotted PVC SLP
Stainless Steel Vee Wire SSV
Stainless Steel Well Point SSP
Section 8
Section 4
Drilling
Method
Drilling Method Code
Air Hammer AH
Air Rotary AR
Auger A3
Cable Tod CT
Casing Advancement CA
Core CR
Direct Push DP
Drive and Wash DV!
Dug DG
Mud Rotary MR
Reverse Rotary RR
Sonic SN
Section 6
Casing
Type
Casing Type Code
Cerla-LOS CTL
Fiberglass FBG
Galvanized Pipe GLP
HOPE HOP
NSF Coated Steel NCS
PVC PVC
Stainless Steel SST
Steel STL
Annular Sea l/Fitter
Pack/Abandonment
Bentonite Chips/Pellets
Bentonite Grout
Cement/Bentonite Grout
Concrete
Sand
Native Material
Section 12
Annular SeallFlter
Pack/Abandonment Purpose
Materiel Code Purpose Code
BC
BG
CB
CT
SD
NM
Pump
Description
Pump Description Code Horsepower
2 Wire Constant Speed Submersible 2WSS 1 2
3 Wire Constant Speed Submersible 3WSS 3'4
Constant Speed Submersible Turbine CSST
Variable Speed Submersible Turbine VSST
Lei
Line Shaft Turbine
Centdtieti
JET
LST
GENT
1 1'2
2
3
1 2
10
15
40
57
60
75
1000
125
150
200
J
Fill FL
Fitter FT
Seal AS
Thickness
Thickness (NO CODE)
Schedule 5
Schedule 10
Schedule 40
Schedule 80
Schedule 160
SDR 13.5
SOH 17
SDR 21
SDR 26
SDR 32.5
SDR•0
17#
194
Section 10
Method
Air Blow with Drill Stem
Air Lift
Bailing
Constant Rate Pump
Variable Rate Pump
Slug
Section 13
Surface Seal Type
Cement
Cement/Bentonite
Concrete
None
Well Seal
Type Code
CM
CB
CT
NO
Method
Code
AB
AL
BL
CR
VR
SG
TYPE OR PRINT ONLY
Massachusetts Department of Conservation and Recreation
Office of Water Resources
Well Completion Report
1A7
1.WELL.LOCATION
I GPS (Required) North iL d a g- l 1 t V West a, ° Y L.L _L d 0
Address at Well Location Z88 e--S4°r 4-e IS eci Property Owner/Client i-cll^^ Ckpp
Subdivision Name: Mailing Address. P.0 • aoX SG/
City/Town: od" c"-n-` rJ City/Town. L7e4 5 MR' 01 O S 3 —65(c
Assessors Map Assessors Lot It NOTE: Assessors Map and Lot # mandatory if no street address
available
Board of Health permit obtained: Yes IA Not Required O Permit Number Date Issued
2.WORK PERFORMED
3.WELL TYPE
4. DRILLING METHOD
6.CASING
Bedrock
From(ft) To (11) Type Thickness Diameter
PJ
h/
D
P1
.5
Overburden
A
71
N
c
do
® aA
/7.#
❑❑ •
5.WELL LOG
OVERBURDEN
Water
Bearing
Zone
Loss or
Addition
of Fluid
Drop in
D 11
Stem
Extra
Fast or
Slow
D II R t
• El
LITHOLOGY
7. SCREEN Nov
From (ft) To(ft)
Code Color Comment
Fr m (ft) To(ft) Type Slot Size Diameter
O
a
G
Q K
)/0
Y /(�
Y /i IV%
F (�
• ❑ •
. — — —
V / N
V / N
F / S
1E1❑❑
V / N
V / N
F / S
❑ S ■
— —
Y / N
Y / N
F / S
8.ANNULAR SEAL/FILTER PACK/ABANDONMENT MR
V / N
Y / N
F / S
From(ft) To (ft) Material Description Purpose
V / N
V / N
F / S
6
do
n1
J�Z1
Y / N
V / N
F / S
❑ •
Y I N
V / N
F % S _
• •
• ❑
V / N
V / N
F / S
'
❑ •
• •
WELL LOG
BEDROCK
Water
Bearing
9
Zone-
Drop in
Drill
Stem
Extra
Large
ipa
Chips
Extra
Fast
slow
D slow
Visible
Rust
Staining
Loss or
Addition
of Fluid
a of
F allures
per tool
9 SITE SKETCH
LITHOLOGY
t ,v
_—�
✓ j,' r-y
J f
/Ys -------�
Il
' /
From(ft) To(ft)
Code
Comment
c1
/00
SC/PN
f�
SCA:4t/lehy/i fe
/oo
/ NY
/
v/ S
Y rill
Y /�1
/Coo
;cm
S91PH
"
/f*'
/ N
Y /
Y / ,
F)/ S
V S
V /C-N,
Y,JV
;./N
V /6)
�co
3W
Sc�ff
t'
fuo
V /(4.
Y / N
Y / N
F / S
Y / N
Y / N
V / N
Y / N
F / S
Y / N
Y / N
Y / N
Y / N
F / S
V / N
Y / N
Y / N
V / N
F / S
V / N
Y / N
Y / N
V / N
F / S
V / N
V / Nj
V / NV / NF / SY / NY / N
V / NY / NF / SV / NV / N
10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
11.STATIC WATER LEVEL(ALL WELLS)
Yield Time Pumped Pumping Level lime t Recove R emery
Date Method (GPM) (firs&min) (Ft. BGS) (hrs&min) ( t. BGS)
Date Measured
Depth Below
Ground Surface (ft)
SP
A3
3 I_ _a : Ya � 30,'
_ _k2 o
sx
5./(7 1-1/4;
3. r
12. PERMANENT PUMP(IF AVAILABLE) NJJA
13.ADDITIONAL WELL INFORMATION
Pump Description
❑ •
❑
❑
Horse ower
Developed Y vN Fracture Enhancement
Disinfect 'Vl N Surface Seal Type
IV /
I'' I
4)
Pump Intake Depth (It) Nominal Pump Capacity (gpm)
Total Well Depth 300r Depth to Bedrock a r
14.COMMENTS
I
15.WELL DRILLER'S STATEMENT
I This well was drilled, altered,�aod/or abandoned under according to applicable
�m/yprescutpervision,
rules and regulations,and/Oils/^sport is com te4J "/ to the„ of my knowledge.
Driller: )?=FtaP % C. "�lr'sire- Supervising Driller Si gnature' -' '-'� r �!! -'-7 `istratioo k: b�
.17 11.-u1701( W(/l tit)/ire: 242 .S/°Cif° / i t 5
Date Complete: % Rig Pe mit#' i / i c (
NOTE: Will Completion teepores must be filed by the registered well driller within 30 days of well completion.
BOARD OF HEALTH COPY
THE CSMMONWEALTTH OF MASSACHUSETTS FEE /5O/6t
6i7— OARD OF HEALTH
Cluj OF NOiTHar pren_I
ION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
t to Construct IX>.Repair f ) Upgrade ( Abandon ( ) - ❑Complete System G Individual Components
tok -Lc -(1D
�g
Wt4Arvc CUPrp( 5W-/763
/0 31 0 46s%AV e7d %!.
aa.
NOpFrccI a
Adarss
fJurL i
Dr 11‘212 Well Permit Payment Record
Dam.
A
Anrorn V 5 1ST rt., Cash Check#4£3
Property Owner /'/a.51.4Q 1 ;. ,
112,pons Address/(ovation k J hitiLki2 k_
tic„ ('onstrvc0on ✓ Repair
JOHN I CLAPP DBA 2583
I' BUILDING & DESIGN
�I PO BOX 561
LEEDS MA 01053
ryj[
PAY IA f DATE as/P4- V° ? , _ -tree xire
�tll oAiiEri OF
__.I..._ $ ct 1
La
tli UV
-_— — -- _. DOLLARS 8 "" i
�ip FLOR E NOS BANK
101U�4,MAIN 6ni11 IE:.FLORENCE 4A O�ptl
FOR Yom/ QS1yF -V yy��� (}/
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