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118 Well Completion Report Section 2 Work Work Performed Performed Code Decommission DC Deepen DPP Hydrofracture HE New Wei NW Repair RP Replacement RE Section 5 Well Completion Report Codes Section 3 Well Type Well Type Code Cathodic Protection CTPR Domestic DMST Geoconstruction GCON Geotnermal Closed Loop GTCL Geothermal Open Loop GTOL lndustnal INDS Infection INJC Irrigation !RAG Monitoring MONT Public Water Supply PBWS Recovery RCVR Test Wells TSTIN Overburden Lithology Name Overburden Overburden (0B)Code Color Artificial Fill AF Boulders 3 Gay CL Coarse Sand CS Cobbles Fine Sand FS Fine to Coarse Sand FCS Gravel G Medium Sand MS Organics 0 Sand&Gravel SG Sit SI Silty Clay SiCL Silty Sand S15 Silly Sand&Gravel SISG Till T Section 7 Overburden Bedrock Color Code Bedrock Name (BR Code) Black BL Bluish Gray BG Brown B9 Dark Gray DG Greenish Gray GG Light Gray LG Reddish Brown RB Yellowish Brown YB Screen Screen Type Code 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 Amphibollm AM Basest BS Conglomeratel&eccia CC!BR Dante DI Gaobro GB Gneiss al Granite GR Limestone LS Marble MA Quartzite QZ Rhyolite RH Sandstone SS Schist SC Shale SH Slate/Phyllite SL/PH Pegmatite PM Section 8 Section 4 Drilling Method Drilling Method Code Air Hammer AH Air Rotary AP Auger AG Cable Tool CT Casing Advancement CA Core CR Direct Push DP Drive and Wash DW Dug DG Mud Rotary MB Reverse Rotary RR Sonic SN Section 6 Casing Casing Type Code Certa-Lot CTL Fiberglass FBG Galvanized Pipe GLP HOPE HDP NSF Coated Steel NCS PVC PVC Stainless Steel SST Steel STL Annular Seal/Filter Pack/Abandonment Bentonite Chips/Pellets Bentonite Grout Cement/Bentonite Grout Concrete Sand Native Material Section 12 Annular Seal/Fitter Pack/Abandonment Material Code BC BC CB CT SD NM Pump Description Pump Description Code Horsepower 2`Wire Constant Speed Submersible 2W55 2 3 Wire Consiant Speed Submersible OWES 25 Constant Speed Suomersibie Turbine CSSI _ Var`atle Sneed Submersible Turbine /SST Sia9 TJrs'n. Centr:;.ea'.. CEP(T 7 100 125 1`D 203 Purpose Purpose Code Fill FL Filter FT Seal AS Thicknes Thickness {NO COD Schedule 5 Schedule 13. Schedule 40 Schedule 80 Schedule 160 SDR 135 SDR 17 SDP 21 SDR 26 SDR 32.5 SDR 40 17e 194 Section 10 Method Method Code Air Blow with Drill Stem AB Air Li! AL Bailing BL Constant Rate Pump CR Variable Rate Pump VR Slug SC Section 13 Surface Seal Type Cema-.. Cement Bemonia CcrIXele None Well Seal Type Coca C:' OR PRINT ONLY Massachusetts Department of Conservation and Recreation Office of Water Resources Well Completion Report 151155 LL LOCATION I GPS(Required) North i—° I K 7 3 1 West l ti- - L s— J-- id 3v0.✓Z Si,I Property Owner/Client. Crr✓t 2J✓it, c r74! :1506,t)!. n.-dL ssatWellLocation Address- S I C vc Name: Mailing vision 5 1-H s if City/Town: 4 „.? .,v it ri Own- A/1671- A/(.p-CW /" Map Assessors Lot#: NOTE-Assessors Map and Lot# mandatory if no street address available ism Date Issued NI I of Health permit obtained: Yes ❑ Not Required Permit Number )RK PERFORMED 3.WELL TYPE 4. DRILLING METHOD • 6. CASING Overburden Bedrock From (ft) To (it) Type Thickness Diameter kW it ✓ T) I f I 0 //- 0 El io ■ ■ ■ ELL LOG OVERBURDEN Water Bearing Zone ✓ Loss or Addition of Fluid Y Drop in Drill Stem Vi'7 Extra Fast or Slow Dr Il Rate F / S El LITHOLOGY 7.SCREEN III) To(ft) 1 ) Code Color Comment From (ft) To (ft) Type Slot Size Diameter //. G' �h // a ».> flI © . 0 / S D44 //.% V / N YIN F / S ■ • ❑ Y I N V / N F / S ❑❑ • Y / N YIN F / S 6. ANNULAR SEAL/FILTER PACRYABANDONMENT RITL. V / N V / N F / S From(ft) To (ft) Material Description Purpose Y / N Y / N F / S ❑ ❑ ill V / N Y / N F / S _ • • • • YIN YIN F / S • ❑ ❑ • V / N Y / N F / S • • ❑ • BEDROCK Water Bearing Zone Drop in Dna Stem Extra Large Chips Ewa Fast or Slow Drill Rate Visible Rust Staining Loss or Addition of Fluid #of F adores per foot 9 SITE SKETCH ELL LOG _ _ _- -' - LITHOLOGY (ft) To (ft) Code Comment Y / NY / NF / SY / NV / N V / N V / N F / S Y / N Y / N Y / N V / N F / S Y / N V / N V / NV / NF / SY / NY / Nil ____ Y / N Y / N F / S V / N V / N Y / NV / NF / SY / NY / N Y / NY / N F / S V / NV / N Y / 4Y / NF / SY / NY / N Y / NY / NF / SY / NV / N V / NV / NF / SY / NYIN WELL TEST DATA ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11. STATIC WATER LEVEL(ALL WELLS) Yield Time Pumped ate Method (GPM) (hrs&min) Pumping Level Time to Recove R covery (Ft. BGS) (hrs&min) (Ft BGS) Date Measured Depth Below Ground Surface (ft) PERMANENT PUMP (IF AVAILABLE) 13.ADDITIONAL WELL INFORMATION ❑ Horsepower Develop d Y 0 Fracture Enhancement Y Ni Y Surface Seat Type tai C 'Iny�' np Description V // Nominal Pump Capacity (gpm) Disinfected , n. Depth to Bedrock np Intake Dept !� (ft) COMMENTS I zt/p LA.;4L'� 4.- Total Well Depth WELL DRILLER'S STATEMENT IThis well was drilled,altered, and/or abandoned under my supervision, according to applicable i,..,. e„a thic raaan is complete and correct to the best of my knowledge. ler: 11 l.I Gf, 0.3 L',r,: j ' Supervising Driller Signature - - - . . Registration #12 I' I / Y-'' I f�fr..w C ✓=)%r>t' s`SS v Date Complete ' 2 ' 3 NOTE: Well Completion Reports must be filed by the registered well driller within 30 days BOARD OF HEALTH COPY Rig Permit#: � P )c' I of well completion.