642 Well Completion Data' OR PRINT ONLY
Massachusetts Department of Environmental Management
Office of Water Resources
Well Completion Report
120626
ELL LOCATION -:
I GPS (OPTIONAL) LATITUDE - ' LONGITUDE
ass at Well Location (el-IQ /UOrt'(r. T. ,r-•- )4? Property Owner l-i- r tch I' ,i' (A'YG
ivision Name: Mailing Address' t)� -_r,_.^' Cam%>o
r
'own: iv)l rV(n h'Pr(,r. LV ,A City/Town- fir. At,,rn kit TiDcoll
r
Y ' r
ssors Map Assessors Lot #' NOTE: Assessors Map
and Lot # mandatory if no street address available
i of Health permit obtained: Yes G Not Required I r Permit Number Date Issued
`
)RK PERFORMED, ,
3. PROPOSED USE
4. DRILLING METHOD
ew Well G Abandon
eepen ❑ Recondition
eplace ❑ Other
Domestic O I rigation
G Monitoring G Municipal
G Industrial G Other
❑ Cable G Auger
E Air Hammer G Direct Push
G Mud Rotary G Other
IL LOG -
1 WATER
eay
Unconsolidated
Consolidated
6.SITE SKETCH (use permanent landmarks with distances)
I (ft) To (ft)
w
h
w
r?
o
m
� -fep
Other
Rock Type
High
Low
-3 ,
=,:,l
GLli
-<#_-14 „11..
y
Jr '
T)17) '
Grid Fie.
__
/;o
LLCONSTRUCTION
8. CASING -
Depth
Drilling
Drilled L+/l
From
From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type
Complete
N
L)C'
ii l RA-4) of
- m m
iThr,JGc•:\LIrIQ
TEEN ”. ... . . . ._
(ft) To (ft) Slot Size Screen Type and Material Screen Diameter
_TER PACK!GROUT/ABANDONMENT MATERIAL
11. ADDRIONAL WELL INFORMATION
(ft) To (ft) Material Description Purpose
Developed? _ Yes ❑ No
Fracture
Enhancement? P Yes No
Method
Disinfected? Yes G No
ELL`TEST DATA(PRODUCTION WELLS)'' - .. ,. -
13.STATIC WATER LEVEL(ALL WELLS)
Yield Time Pumped Drawdown to Time Recovery to
e Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. KS)
Depth Below
Date Measured Ground Surface (FT)
',RMANENT PUMP (IF AVAILABLE)
15.NAME/ADDRESS OF PUMP INSTALLATION COMPANY
Description C-#-.- - 2 ; e Horsepower
_-L-, T M .
Intake Depth X44.1 (ft) Nominal Pump Capacity r- (gpm)
IMMENTS
ELL DRILLER'S STATEMENT I
This :well was united and/or abandoned under my supervision. according to aooiicacle rules
and regulations. and this noon is complete and correct to :he pest of my knowledge.
l'P(, 4 +N , -. r1 I Supervising Driller Signature' - rt r. .,(„__ ' °I i
_r- Registration 4'1 nI
L-(Vs i � ". . ;hC'_� yi C . Date. ,. . - : I i r •N II
Rio Fermi[ #
NOTE: Ue/l completion Reports must be filed by the registered well driller within 31)days of well completion.
90A RD OF uEALTU r•nay