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HomeMy WebLinkAbout0194 MAIN ST./RTE 6A(W.BARN.) - Health 1�4 1Vl~ain street/Rte 6A West-Barnstable A 134 024` l 0 11 :j ro i, «;•:r it a — c i r't , y r e �I Om lord NO. 152 1/3 BLU �;�� 10% Massachusetts Department of Environmental Management 108040 ®�0 n0 Office of Water Resources TYPE OR PRINT ONLY Well Completion Report 1.WELL LOCATION GPS (OPTIONAL) jj LATITUDE m LONGITUDE = _ Address at Well Location: o Co Property.Owner: �S z`/Q E F Subdivision Name: - Mailing Address: EL City/Town: _64). &e_A&S_146LE Citylrown: V/ M p- O ` Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot#mandatory if no streetaddress available Board of Health permit obtained: Ye� Not Required-❑ Permit Number(Aan j�D t,Issued` - "d 2. WORK PERFORMED 3. PROPOSED USE 4.DRILLING METHOD New Well ❑ Abandon omestic ❑ Irrigation ❑ Cables ° ger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air HammerrO Direct Push El 'Re lace El Other El Industrial El Other ❑ MudRota _,❑ Other S. WELL LOG IY Unconsolidated Consolidated CL SITE SKETCH(use permanent landmarks with distances) W Penneabiliry From (ft) To (ft) Other Rock Type p 7.WELL CONSTRUCTION 8: CASING f Total Depth Drilled From'(ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type n Date Drilling Complete f — 41&i1 9. SCREEN From (ft) To (ft) Slot Size M Screen Type and Material Screen Diameter - r ��e Q/ r! 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL 11.,ADDITIONAL WELL INFORMATION Developed? es El No From (ft) To (ft) Material Description Purpose Fracture Enhancement? ❑ Yeslo . ° Method Disinfected? ❑ Yes o 12.WELL TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Depth Below Date , Method (GPM) (hrs&min) (Ft. BGS) (hrs& min) (Ft. BGS) Date Measured Ground Surface (FT) 14."PERMANENT PUMP(IF AVAILABLE) _ 1&NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description - Horsepower Pump Intake Depth + (ft) Nominal Pump Capacity (gpm) 16. COMMENTS ? '17.WELL DRILLER'S`STATEMENT $ - This well was drilled and/or ab ndoned under my supervision, according to applicable rules and regulations, and this repo pis completeand correct to the best of my knowledge. Driller. jj�,, ��f A� ervisin Driller Si nature: r r\ f Re istration #: // ,',, P 9 9 9 Firm: �l� W EL ( �� !� C' Date: ��_:f� �L-- RigPermit#: NOTE: Well Completion Reports must b led by the registered well driller within 30 days of well completion. �. k a< x• r . :BOARD OF'HEAL 1GH,.COPY "a 6 F }. + t .t i ♦ F ... ^' $ . ti h $ k x i♦`. - f Rq. F..Q.l k p h Y 4 t r . k kk f l f-... i$ r 1.k C 1 V 4.. - 4. £i,i.4 s i♦ - r J Ar. 71, r f`ea �.4 • 't ' ay 1 f • i V ' �1 1 f L � t_ �'1, .. k i i �� �t � 1 1 •i f 1 i ! � - 4 t t f • ? i J 7.f'.00 1 { i 1 1 �. •.•. .... _ . _ -...tee. - r _�. -. - � -—+' �. _ -_ - 1 • r 4 .:i.l -4-•Ei'l t IZ'J' __. a�'. :a'. r5` 'i.ii..:-+- .�.'{� . �3.at_'�." � ! �_t -� ;i�,♦ ' r + 18.8 + 18.1 LOT 4 1oo. 50' 18.9 129,334 SFf - + J 15.9 14.0 1 � 9\ + 18.8 + . A+ .3 + 9 �0 + 1_.5 ,s8 50.o' ��. 8 + 3.2 + 8.3 + .3 I + I a.8 BENCHMARK - TOP OF \ h 14.1 CONCRETE BOUND \ LOT 3 EL. = 18.7'(NGVD) \ } 13.d- + 1 4 + 19.2 I\\\1 r 219' i 3.4 n + g� TH1 �60 /, y 0. + 14 :3.9 + 13.; + 14 7 25 7.3 � -` PROP. DWELL. - .0 )o , TOP MON =25.0' J 163 70 ro +/3 .6 � _ + 1 14 N \ r T `Qa p '� i �\\ 4 I �s` ♦bU� + 16. + I .E 2 © + 9.5 ROP. WELL /�I / �\ ,;•i' 23. �cr 1 3 ,5 r )+128.7 1 �N tia / i � • � 202 i - GAR / \ 5°. �+ 1 .9 2�J.E?O.B G�v o � g II / , �y 25 ��, ;LT • �30 s �pP• / rl � � C� ^ J C 2 .9 + 21.4 4NIfy P c, r �� ti f TOWN OF BARNSTABLE LOCATION(/ �t!T SEWAGE # VILLAGE /,�� ���. � ►SSESSOR'S�MAP& LOT 0:Z q INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type ���r f�� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: `Maximum Adjusted Groundwater T'able to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rMP;A 5� 11 _ r No. c �S� Fee / ( f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Migoml bpotem Conztruction Permit Application for a Permit to Construct(�epair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. ;�Ll �A ✓v 4 j. Owne's N e ddress and 1.�Io. Assessor's Map/Parcel i �?�(rh i�l�. 1 Z fue l L. e-t'a l e ce"+V_L1 T`j e V_ Installer's N e,Address,and Tel No De i er's Name,Address and Tel.No4 N s ��.VK p6-uW �E f;J6fI.,f4' ;?l'A;6 Type of Building: Dwelling No.of Bedrooms Lot Size 7c5494,Vsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5-5-0 gallons per day. Calculated daily flow GL gallons. Plan Date U'Ics,® Number of sheets Revision Date Title -T1'71,6_ S �t f-OA✓ Size of Septic Tank 5-V—0 fe. . Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is b al 1'i. Signed Date � Application Approved by Date Application Disapproved for the following reas ns Permit No. "S Date Issued No. p�iwcY7'�S ��7p �► -^- j Fee !t�, ''r.'. l THE GOMMQN!W ALTH OF MASSACHUSETTS IL tiered in computer: Y z PUBLIC HEALTH-DI,VISION TOWN;OF BARNSTABLE"MASSACHUSETTS.: - = - ` Yicat on four Woo Construction Permit Application for a Permit to Construct(Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i L1/�A N 5 I ; owner's Name ddress and el.r1o. /". 1 1 "Ins► a a--Ct wM(1g� l Assessor's Ma /Parcel }� 7 p p , : y/�rz w G��S ,2 f0e( � ct r��P i Installer's N e,Address,and Tel.No. ; l De ' ner's Name,Address and Tel.No, N s ExIv _ _ Type of Building: t Dwelling :No.of Bedrooms Lot Size ?,C►�1c7�it✓sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow l9� T gallons. Plan Date 0—t lCK O Number of sheets Revision Date Title `T ITI-6 Size of Septic Tank .S f9 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable). - Date last inspected: `, 'i M Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cite of Compliance has been i - b Aar f al r i Signed Date Application Approved by26 Date 7�--/7' Q l r. Application Disapproved for the following reas ns I ll D Permit No. 3S l Date Issued 7 l� � '.,., - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS , Certificate of Compliance — THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( -JoRepaired ( )Upgraded( ) Abandoned( )by at d Gj 141Gti1.✓� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated �7 "l0 — a 1. Installer Designer The,issuance'of this permmit shall not be construed as a guarantee that the system will fu ctiot�v is designed. Date 171110/-2.00 i Inspector d-1t . .,I , — -------------- No. Z -- - Fee /yu/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Mi5pogaY # !61em Construction Permit Permission is hereby granted to Construct( p)R pair )Upgrades( )Abando ) System located at L C) �,, �J ✓✓ �' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction st b co eted within three years of the date of thi e Date: ® Approved by 4� t No. {�__�� Fee BOARD OF HEALTH TOWN OF BARNSTABLE Application for lVell Construction Permit Application is hereby made for a pe it to Co struc ( ), Alter ( ), or Repair ( )an individual Well at: oj -- L ation — Address Assessors Map and Parcel — a� �r1� Address — — _—_——// -- —----------- -- -- ------ --------—------- --------- ------------------------- Installer — Driller Address Type of Building Dwelling --- — -- — -- --- Other - Type of Building No. of Persons------------------ YP $----------------Type of of Well -- —--- - Capacity---------------- --- -— Purpose of Well --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed — —__—_ __— _—_-- —___--- dra�te- Application Approved By - -------- �G date Application Disapproved for the following reasons: date Permit No. --- Issued----------__-- ------- _---___-- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( , Altered ( ), or Repaired ( ) by — ------ --- -- - - —------- — Installer _ at— has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----_ - Inspector----------------___—__--_—__--___-- Fee-------------------- BOARD OF HEALTH ''" y TOWN OF BARNSTABLE' AppiicatioufforVeir Con5tructtonpgT t Application is hereby made for ape it to Co struc ( ), Alter ( ), or Re air ( )an individual Well at: dl- - L ation — Address A sors p and Parce; j wner Address Installer — Driller Address Type of Building Dwelling --- ---------- Other - Type of Building----------- -- No. of Persons--------------------._--______ Type of Well ------ Capacity---------------------- Purpose of Well --- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed - — ----— - — _— — — Application Approved By,�/�� !�`'�`—= date Application Disapproved for the following reasons: date -- Permit No. -- Issued-------- ---- -- --- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif icatr ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( , Altered ( ), or Repaired ( ) r: ,. Installer at- - — -__—_--—--- - - --- ------- —�—_-- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. - ------- ---Dated-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- -- — -- Inspector - . r BOARD OF HEALTH TOWN OF BARNSTABLE " eff �;oustructYor� er it �// No. ------ Fee --_--_ Permission is hereby granted - ---- -----— -- — to Construct ( , Alter ( )%or Repair ( )��I�vidual Wf l�,at: No. — _� __ ___ � _ - -7 Street as shown on the application for a Well Construction.Permit No.- GcJ (-4 —� _ -f Dated- - -- - - -- — ----Zlef;�—�-- Board of Health DATE / — TOWN OF BARNSTABLE LOCATION SEWAGE # 0 0 1 VII.LAGE r -S .SSESSOR'S MAP & LOT 13 Yk a q INSTALLER'S NAME&PHONE NO.� SEPTIC TANK CAPACITY ,/�0 / LEACHING FACILITY: (type C I�S� (size) /Z X NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: =)r P COMPLIANCE DATE: 12 1# U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland.and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r F i ,v No -1 ------- Fee--- -- -- -------- BOARD OF HEALTH TOWN OF BARNSTABLE Zpphration-*rlftl Con5truttionpermit AM"F!OF-�- ' hereby ade for a pe 't o struct (!X), Alter ( ..),,or Repair ( )an individual Well at: �,��y p --; - - , - --- -- -------------------------- ---------------------------------------- - ----------------- ` � �Afldrea5� �J ssessors Map and Parcel ----------------------------- - - --- ----- -- - -------------------------------------- -------- --------- -- ---- - ------------ -------- --------- Owner Address --------------- ------ Installer — Driller Address /f Type of Building � DwellingLv= --------- Other - Type of Building-------------------------- No. of Persons----------________ _____________—__________ r-to Type of Well---- -- - - ---—- -- -- -- - - Capacity------------------- -- --------------------- Purpose of Well----- �'` �--- — -- -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation un4. Certi is to ,' e has been issued by the Board of Health. Signed- ----------------- -- ------- --------fl?-------------------- a ate Application Approved By-- -�- - -- -- - --------------------------------------- date Application Disapproved for the following reasons:- -- --------------------------------------------------------------------------------------------------- ----- -------------------------------------------------------------- date -Permit No. -----------=--- --- -------------- -------------------- Issued----------------------------------------------------------—---- ------------------- " date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compriante THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) - --_—__ — -- - -------------- --------------------—---------- Installer at— ---- - - - -------------- -- ---- -------- --- - -- --- ---- - -- —=- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------------Dated-------------________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------- ------------------------------------ Inspector----------------------------------------------------------------------------------- �1 Fee—_ c - - L✓--I-•-- ------- t BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rWrit Cootruction Permit ti Application is hereby ade fqr a .pe it t Construct ( ), Alter ( ), or Repair ( )an individual Well at: --------- ---------------------------------- -- ---—----_-- �, } d'c Address' Assessors Map ^ a? and Parcel -- ------� --------- -------- Owner —._ y Address C/• � _ e�-�- ----------- Installer:—, .Driller ) Address f Type of Building Dwelling--------- -----f 4DR_ --------------------------- Other - Type of Building --------------- No. of Persons----------------------------\-------- ` w Type of Well— --------------------- Capacityn_ ------------- Purpose of Well----`-? 1�'`1 �� --- - - - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unttiil�a/Certif c too In Toe has been issued by the Board of Health. Signed---;----- -- --- --- ------------------- -------------------------- o ��-- T— date. Application Approved By- --r -'---------- date ----- -----_ to __---- u � a Application Disapproved for the following reasons:------------------------------ __ --_— —--- - - --- -- -----------------•------------------------------------------- date Permit No. - _--- - - Issued - - -------------- date BOARD OF HtALTH ` TOWN OF BARNSTABLE Certificate ®f Compliance ' j THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) - ----------------------------------------------------------------------------------------------- Installer at---— ---— - — - - --- - - —-------------------------------------------------------------------------------— ----- ---- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----------------Dated---- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------------- Inspector----------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Well Cootruct ion Permit r ;� No. I A -q/7�---- d `� Fee* - oko )�7 A6- Permission is hereby granted---, , _ to Constr ct ( � Alter ( ), or Repair ) an Indivi ua'1'Wel) t: 8— A 2 A- )— (10a, 6 P Skeet as shown on the applicati fo a Well Construction Permit � r ---------------------------- 4te -�-No. L <v= - 'r -�___-- - -—^—� __;o 44� Board of Health- • DATE ---- -- 1"=' - -- -------------------------