HomeMy WebLinkAbout0349 BEARSE'S WAY - Health 340 Bearse's Way
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COMMONWEALTH OF MASSACHUSETTS I �
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS : "
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
I 341 CERTIFICATION
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Property Address: 3)43EARSES WAY HYANNIS,MA 02601Owner's Name: HM. NISSLEY Z ,,.'.`
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Owner's Address: 63 SPRING ST HYANNIS MA 02601 'iw
Date of Inspection: 12/3/01 ' T
RECEIVED ` ';
Name of Inspector: (please print) �,i JOHN GRACI "° ' • ,,f,
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 �dr
DEC 2 0 2001
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Telephone Number: 508-564-6813 FAX 508-564-7270
TOWN OF BARNSTABLE
HEALTH DEPT. }
CERTIFICATION STATEMENT 1 '
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below isI:i
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and r,
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experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ,V'+
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X Passes
_ Conditionally Passes
_ Needs Fu• Evaluation by the Local Approving Authority ' 'n'
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Fails • w �r�x
M x
...
Inspector's Signature: Date: 12/3/01
The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within r �'
30 days of completing this inspe tion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
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inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be ;s
sent to the system owner and copies sent to the_buyer, if applicable,and the approving authority. t ` Y,
Notes and Comments `t; .t:
PUMPING EVERY YEAR TO PROLONG THE SYSTEMS
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND :a '�sA.
s USEFUL LIFE. r Fk b
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This
i inspection does not address how the system will perform in the future under the same or different conditions of use. :, %fir-:.
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Page 2 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
i'17•S� t 7.
CERTIFICATION (continued)
Property Address: 343 BEARSES WAY HYANNIS,MA 02601
Owner: HELEN M.NISSLEY ti.
Date of Inspection: 12/3/01 '
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Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 :uw1
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
14.,-.,
Comments:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY YEAR TO PROLONG THE �t ks'.. •
SYSTEM'S USEFUL LIFE.
• i
B. System Conditionally Passes: s
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, $ 'x
' upon completion of the replacement or repair,as approved by the Board of Health,will pass.
d 4ti:_
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exftltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health. is
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating ; 7�
that the tank is less than 20 years old is available. a .
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ND explain: n/a '
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
or due to a broken,settled or uneven distribution box. System will ass inspection if with approval of Board of
pipe(s) Y P p ( PP
Health):
_ broken pipe(s)are replaced
_ obstruction is removed `` :
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
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inspection if(with approval of the Board of Health): Ati
_broken pipe(s)are replaced : ' .
_obstruction is removed
ND explain: n/a7
} ` s + 2:.
' ;!15
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Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS ` '-�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '•` '-
PART A
CERTIFICATION(continued) $
Property Address: 343 BEARSES WAY HYANNIS,MA 02601 ;
Owner: HELEN M. NISSLEY
Date of Inspection: 12/3/01
.F
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
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1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is s ;{
not functioning in a manner which will protect public health,safety and the environment: '
_ Cesspool or privy is within!50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the ;? . y
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water „ .
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water 4.
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia . ys
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy s A,:41
of the analysis must be attached to this form.
3. Other:
n/a
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Page 4 of I I "
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r '�
PART A ;
CERTIFICATION(continued) w,; l
Property Address: 343 BEARSES WAY HYANNIS,MA 02601 � ;.
Owner: HELEN M.NISSLEY
Date of Inspection: 12/3/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No V. ,
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
� .
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %:day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times ;., ,F.�
pumped nLa. �yY
X An portion of the SAS,cesspool or privy is below high round water elevation.
Y P P P �'Y g g
X Any portion of cesspool or prig?is within 100 feet of a surface water supply or tributary to a surface water supply. ,A,�?��:
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP ':
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or '
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be w i
attached to this form.]
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(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 IT
CMR 15.303,therefore the system fails;The system owner should contact the Board of Health to determine what will be ,
necessary to correct the failure. .x,.
E. Large Systems:
To be considered a large system the s' stem must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: 4.T
(The following criteria apply to large systems in addition to the criteria above) ;
t. •,l,if�{�.r,
yes no a <.s ~
X the system is within 400 feet of a surface drinking water supply ;.
X the system is within 200 feet of a tributary to a surface drinking water supplyxr'_
X the system is located in a nitrogen'sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply wellf:.,
.Y M
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered4a '
yes in Section D above the large'systein has failed,The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
pg Y Y
should contact the appropriate regional office of the Department. s
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Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS w,,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART B `'
CHECKLIST
Property Address: 343 BEARSES WAY HYANNIS,MA 02601
Owner: HELEN M. NISSLEY :'t,
Date of Inspection: 12/3/01
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided b the owner,occupant,or Board of Health
P g P Y ,
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X Were any of the system components pumped out in the previous two weeks? �
X _ Has the system received normal flows in the previous two week period?1 °�Vn
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A) 1.
X _ Was the facilityor dwelling inspected for signs of sewage back u ? t v t
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank ma"61es uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ; :
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance "b"�ft•
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of subsurface sewage disposal systems
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The size and location of the Soil Absorption System(SAS)on the site has been determined based on: rtx3;
•�vR�/' t�Ll
Yes no � `�k
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) 310 CMR 15.302(3)(b)] n:. .
Si ...
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Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .+
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMS
PART C
SYSTEM INFORMATION
Property Address: 343 BEARSES WAY HYANNIS,MA 02601 -` '.'•�_*
Owner: HELEN M. NISSLEY
Date of Inspection: 12/3/01
FLOW CONDITIONS
RESIDENTIAL `;"''
Number of bedrooms(design): 3 ' Number of bedrooms(actual): 3 '`
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 7 .
Does residence have a garbage grinder es or no): NO ;
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] ,z-,
Laundry system inspected es or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a " .
Sump pump(yes or no): NO
Last date of occupancy: n/atL , :
COMMERCIAL/INDUSTRIAL .; -
Type of establishment: n/a
Design flow(based on 310 CMR 15.203):'_n/agpd ,;,<..
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO 1' •^'
Fr<S:�m-a
Non-sanitary waste discharged to the Title 5 system(yes or no): NO s
• i.e.,...
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a T'
GENERAL INFORMATION
Pumping Records ° xa
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NOk' fir.
If yes,volume pumped: n/agalIons--How was quantity pumped determined?n/a
Reason for pumping: n/a
4T..
TYPE OF SYSTEM 5 `,
X Septic tank,distribution box,soil`absorption system ,,1
_Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any) =`, '
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from: r 1 spa
system owner)
_Tight tank Attach a copy of the DEP approval .
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information: ta
50 Y RS "
Were sewage odors detected when arriving at the site(yes or no): NO `
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Page 7 of 11
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OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Kkc
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 BEARSES WAY HYANNIS, MA 02601
Owner: HELEN M.NISSLEY
Date of Inspection: 12/3/01 ; : *11 o'.
BUILDING SEWER(locate on site plan)
Depth belowgrade: 14"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.): 'R"
.4:
TOWN WATERs`?
SEPTIC TANK: X(locate on site plan)
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Depth belowgrade: 8"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age'confirmed.by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"
Sludge depth:2" '
Distance from top of sludge to bottom of outlet tee or baffle:32
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6" .Ff
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related-
to outlet invert,evidence of leakage,etc.): F
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. .< ._y,s.
RECOMMEND PUMPING EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. bra.
GREASE TRAP:_(locate on site plan) '
Depth belowgrade: n/a
Material of construction:_concrete metal fiberglass_polyethylene_other(explain): n/a
F.3
Dimensions: n/a �� "• ,.,
I Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a �►'
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a `
Page 8 of 11
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OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS 'a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C ' ° -
SYSTEM INFORMATION(continued) '}
Property Address: 343 BEARSES WAY HYANNIS,MA 02601 �' •+
Owner: HELEN M. NISSLEY ;k t
Date of Inspection: 12/3/01 ` i{
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a ^y .`'g
Material of construction: concrete metal fiberglass_polyethylene—other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons a
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A '"i
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a `
Comments(condition of alarm and float switches,etc.): i ri?
n/a ..,..
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) ,
Depth of liquid level above outlet invert: n/a
J-,
Comments(note if box is level and distribution'to outlets equal,any evidence of solids carryover,any evidence of leakage into ,�"� d
'.4*
or out of box,etc.): 13. .
n/a
PUMP CHAMBER: _(locate on site plan) x% .
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
1 Comments(note condition of pump chamber,,condition of pumps and appurtenances,etc.): fi.�'h,
n/a
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART CFN.
SYSTEM INFORMATION(continued)
Property Address: 343 BEARSES WAY HYANNIS,MA 02601
Owner: HELEN M. NISSLEYf .T''
Date of Inspection: 12/3/01 rti
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
yYyY
If SAS not located explain why:
Type
1000 GAL 6' X 6' leaching pits, number: 1 '� •r
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a i �rt
n/a leachingfields, number:
nla
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology:T
YP 9Y� n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): ; _ r
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT HAS F OF LEACHING LEFT .� •
AND THE BOTTOM IS AT 81. Fv'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) '`.
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a :'"yy,';°�1'(�•
Dimensions of cesspool: n/a t:' n
Materials of construction: n/a '�
Indication of groundwater inflow(yes or no): NO w
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): f;
n/a t �
n,
PRIVY: (locate on site plan)
Materials of construction: n/a �,_
Dimensions: n/a
Depth of solids: n/a
Comments note condition of soil signs of hydraulic failure level of ponding,condition of vegetation,etc.): n :.
Co ( g Y P g, g
n/a ,+ {•4
Page 10 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 3' 'q J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART C
SYSTEM INFORMATION(continued)
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Property Address: 343 BEARSES WAY HYANNIS, MA 02601
Owner: HELEN M. NISSLEY
Date of Inspection: 12/3/01
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SKETCH OF SEWAGE DISPOSAL SYSTEM } '
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building. i •` "'
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Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 BEARSES WAY HYANNIS,MA 02601
Owner: HELEN M. NISSLEY
Date of Inspection: 12/3/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
.qe-5 Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavator's, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT. NO WATER WAS ENCOUNTERED.
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